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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z' <br /> AME OF FACILITY Rt p� �arr� SCY'�((L e. WEEPS CODE <br /> DRESS 1 a ag' HJ q Cj ANK ID # - <br /> TANK SIZE —FUEL TYPE -gq- IC,05-01 - 10,000 dLc7seI <br /> 0z ' 1�,500 A(Cse I <br /> II_ GENERAL SITE HISTORY OS - )o,000 un�a <br /> OLf — 16,000 dLese l ,* <br /> Is permit current? es o ermit # acility Status Code Sa oc.Soil/GW Con ITes o <br /> umber of Tanks at facility q-- ge of Tanks(if available) v V-1 rgl ngt -0ual <br /> 111. TANK HISTORY rev 1xr vcd Co is • g <br /> as Tank tested? If esailed precision test ? as o If yes, give date(s) <br /> H <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair time under inspection? If <br /> es 40 ere soil samples analyzed? es I o I TXE I PH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfiLl nknown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water 1,,90 of/Year � ;S-I, verage Annual Precipitation = 4 0-25 <br /> n-Site WeIL(S) es o umber 8 Type Irr I om I ub <br /> S Score S Score S Score <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditi on R condition 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) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX 00 9 10-25 xxxxxx 26-40 <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) More Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wails. At Least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> Sample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> R <br /> B T X E B T % E <br /> MAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: --*If documented soil and/or ground water contamination is present, do not complete 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 net use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BT%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ; bxMQ ,{00kLQ/_.+ �(,,,, <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o ��` W I `^�" '�"b,C ,C C4 <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION If <br /> ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> 23 80 (UGTWKSHT)\5/90 <br />