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SAN JOAQU` XNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *-ALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE � - •�� <br /> AME OF FACILITY ��WQV'U PecLce n-JI o-9- WEEPS CODE 185 g <br /> %DDRESS rOL!5 1 N• 101 -Q- '��(�.Q.t/\ ANK ID <br /> YANK SIZE ?Jr-o a UEL TYPE �f <br /> It. GENERAL SITE HISTORY <br /> Is permit current? es o ermit s act I ty Status Code !j Q x.Soi t/GW Cont CS o <br /> umber of Tants at facility ge of Tanks(if available) ype of Tent teal I brgl I ngl I Dual <br /> Ili. TANK HISTORY tri,5t0,tLtFk 196 <br /> ns Tank tested? es o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> ns repair done under inspection? as No ere soil samples analyzed? as I L+,— TXE -G Px• b/EDG <br /> Type of failure/discharge atastrophic long-term leakage verfitl I knkn,wri ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received qv1io epth to Ground Water 111) of/Year r ; T(, verage Amuat Precipitation = 4 10.25 <br /> )n-Site Wetl(s) Ifes o I umber 8 Type I Irr omub <br /> S core S core s core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R audition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) ��p,C)=1o5 �D >100 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None a Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10.25 xxxxxxx 26.40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None -I Unknown Dresent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None // one �n7one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> 'ample Result: (0 T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> f'� s14% <br /> 6 T X E B T X E <br /> MAXIMUM ALLOWABLE G-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> N ^ A%INUH ALLOWABLE TPN LEVELS (PPM) <br /> C� TPN IESEL 10,000 1000 100 <br /> FOOTNOTES: "'If documented soil and/or ground water contamination is present, do not cooptete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points-. If depth <-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXBE are rot applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> 1• Are BTX 8 E or TPN Concentrations > Allowable Levels Yes I IN01 <br /> I2. Recommend Site Closure 's o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION • TO BE CCMPLETEO BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERREO TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> ANE OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />