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SAN JOACUIN COUNTY*LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH *ION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE y 1/i <br /> -•1"+E OF FACILITY � 1 f 7 <br /> n..i►� it <br /> l <br /> CtC 6,,11 e�) EEPS CODE LY <br /> DD RE SS (sem j / <br /> 1 •R• J ANK 10 x q <br /> ANK 512E 1 OO 0 UEL TYPE <br /> It. GENERAL SITE HISTORY <br /> EgNT!!]ge of Tanks(it available) <br /> ype of Tank Leel Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> .as Tank tested? es 0 ailed precision test '+ es <br /> • o It yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was r <br /> epaireU.+ <br /> ns repair done under inspection? es o <br /> era soil samples analyzed? ras to 1 1,T%E I ITPM-G PX-D b/E06 <br /> YPe of failure/discharge atastrophic Long-term leakage verfill nknown <br /> cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT rOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 0 epth to Ground water <br /> V0 of/Year verage Annual Precipitation 4 10.25 <br /> n•Site ueLl(S) es o umber S Type Irr 0M <br /> ub <br /> istance to WeIL(S) from TankftS core S core S core <br /> ; ft; ft C 0 pts C <br /> 0 Ate 0 pts <br /> if <br /> 0 it O 'f <br /> Site Feature - Leaching Potential Analysis R ondition R onditn on R ondition <br /> E 's met E is met E 's met <br /> inimum Depth to groundwater frau the Soil Sade (feet) <br /> )100 1.100 � 25.50\1 <br /> ractures in Subsurface (applies to foo[hills or mountain areas) ( U None Unknown <br /> resent <br /> verage Annual Precipitation (inches) <br /> xxxxx <10 9 10-25 xxxzxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) A <br /> None 1 Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. <br /> At least ore than <br /> xxxx cane one one <br /> COLUMN TOTALS>>>TOTAL POINTS I C I� 5 -a <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 ptS 0 pts or less <br /> —�_ ,,PA4 G i X E 9 T % E ___ <br /> MAXIMLM ALLOWABLE O-T-X-E LEVELS (PPM) 1 50 50 50 .3 ,3 X 1• <br /> 'ample Result: NA\3 <br /> A%IMl1M ALLOWABLE TPN LEVELS (ppM) ASOL(NE 1000 100 10 <br /> TPN IESEL 10,000 1000 <br /> 100 <br /> OOTNOTES: •'*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 grout water.) <br /> V \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX8E are rot applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br />. 5TAFF RECOMMENDATION/CONCLUSION <br /> R <br /> AreX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> mend Site Closure es o if Yes, R er to Site Mitigation forVALUATION • TO BE COMPLETED 0Y A SUPERVISOR SENIOR <br /> H STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATIONRED i / All CLOSURE LETTER MAILED <br /> I <br /> FN 23 80 (UGTWKSHT)\ ,'� <br /> F'I3 2° LO <br />