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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION - <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION IlATE / / — <br />AME OF FACILITY WEEPS CODE 3 <br />DRESS LL 7L' �I J <br />ANK ID '# <br />TANK SIZE 6; j T-� UEL TYPE - <br />I1. GENERAL SITE HISTORY <br />Is permit current7 es Ivo !Permit AT C / ? acility Status Code oc.Soll/GW Cont ea o <br />umber of Tants at facility ge of Tank s(if available) �7>� Type'of Tank tact Fbrgl ngl Dual <br />111. TANK HISTORY <br />IV <br />as Tank tested? <br />es <br />IV <br />0 <br />ailed procision test 7 <br />es <br />of/Year <br />o <br />! '- If <br />yoc, give date(e) <br />4 <br />as a repair made to the tent system? es No ^�� f yes, repaired? <br />)n -Site Welts) <br />as repair done oder inspection? <br />es o <br />--what <br />ere soil samples analyzed7 <br />es <br />umber 5 Type <br />o <br />Irr <br />ITKE <br />I <br />PH -G <br />I <br />PH -D <br />Score <br />10 pts <br />if <br />undition <br />is met <br />b/EDD <br />Score <br />9 pts <br />if <br />ondition <br />is met <br />Type of failure/discharge <br />Score <br />i pts <br />if <br />-ordition <br />Is met <br />otos trophic <br />lon8-term leakage <br />vert ill <br />iniuum Depth to groundwater from the Solt Swlple (feet) <br />awn <br />I <br />IDther: <br />• ^�^�•�6 n.>iun, awl IALn INsreLl ION NLI'UNT FOR SITE DETAILS/COLLECT DATA Gro IFArwluc outrun Al Au>i vcic. <br />'oil Samples Received <br />es <br />V <br />o <br />ep[h to Groud Water <br />of/Year <br />ikveCaqe Annual Precipitation <br />• <br />4 <br />0.25 <br />)n -Site Welts) <br />es <br />100 <br />0 <br />umber 5 Type <br />ATE REf ERRED <br />Irr <br />ATE CLOSURE LETTER MAILED <br />an <br />ub <br />S <br />c <br />0 <br />x <br />E <br />Score <br />10 pts <br />if <br />undition <br />is met <br />S <br />C <br />0 <br />A <br />E <br />Score <br />9 pts <br />if <br />ondition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />i pts <br />if <br />-ordition <br />Is met <br />is[ance to Wet ITS) from Tan[ <br />ft; ft; _,T_ft <br />Site Feature - Leaching Potential Ara tysis <br />iniuum Depth to groundwater from the Solt Swlple (feet) <br />>100 <br />-1.100 <br />25-50L <br />fractures in subsurface (applies to foothills or mountain areas) <br />Mme <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />xxxx <br /><10 <br />9 <br />10-25 <br />xxxxxx <br />26-401 <br />un -Made conduits which increase vertical migration <br />I leachate (i.e., septic syataLs, water wells, ponds) <br />None <br />Unknown <br />Present <br />pique site features: Recharge area, coarse soil, nearby wells. <br />" <br />xxxx <br />None <br />At least <br />one <br />4ore than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />% <br />L,L <br />'duple Resul/t�:�(B T x ON E) <br />FTI I= N ED <br />RANGE OF TOTAL POINTS <br />9 pts or mora <br />41 40 pts <br />40 pts/or less <br />MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) <br />81 <br />1 <br />50 <br />x <br />50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />I x <br />1. <br />I E <br />1. <br />NAL <br />ample Result: <br />At I= N D TPH <br />ASOLINE <br />IMUM ALLOWABLE TPH LEVELS (PPM) <br />IE <br />1000 <br />100 <br />10 <br />SEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: •••1 documented soil and/or ground water contamination is present, do not calplete the leaching potential <br />analysis. (i.e., site Is currently on UGT Contamination Lis[ for soil or grand water.) <br />.�,1 If depth is > 5 ft. "<6 ft., score 0 points. If depth <=5 ft., do net use table. <br />,L2 If precipitation Is > 40 inehos, store 0 points. <br />L Levels for HTXAE are not applicable at a IPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION 0,-)- cze :6 /a rx y C TP/1 <br />1. Are HTX 8 E or TPH Concentrations > Allo to Levels Yes o `te G / / <br />2. Recanmand Site Closure 1Yes iTo If Yes, Refer to Site Mitigation for Evaluation <br />V11. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />US <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REf ERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />ANE OF <br />VALUATOR <br />Ln a5 -- tuulwK. ni)%J/Ya <br />