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SAN JOAQUIN CCUNOBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH01SION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE lie -,(1 <br /> ,AHE OF FACILITY � . e�J��_ G. , L�,,/�SL���J EEPS LOOE <br /> DORESS n��d �, jlL.{�/1.1:-n7,,,E —L-tem JZ-�-t [,iJGx-<- ANK ID # <br /> ANK S12E Z>(�Q UEL TYPE .�"t 016 <br /> II. GENERAL SITE HISTORY <br /> .s permit current7 es o ermit # acility Status Code oc.Soil/GW Cont 1Ycs !o <br /> wnber of Tanks at facility ge of Tanks(if available) I IType of Tank teel Fbrgl ngl Dual <br /> III, TANK HISTORY <br /> :as Tank tested? Ifes o ailed precision test ? ifas o If yes, give date(s) <br /> as a repair made to the tank system? 1Yas No f yes, what was repaired? <br /> ns repair done under inspection7 es o ere soil samples analyzed? es to TXE PH-G PH•D b/E00 <br /> ype of failure/discharge atastrophic Long-term teakage verfill I kknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Receivedes o epth to Ground water S�� of/Y car }S �; verage Annual Precipitation = 4 10.25 <br /> -Site wcll(s) as o umber 3 Type Irr an ub <br /> 5 Score S Score S core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R condition R ondition <br /> Site Feature - Leeching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sade (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) /h None Unknown resent <br /> e <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10.25 xxxxxx 26-40\2 <br /> on•Made conduits which increase vertical migration <br /> ! leachate (i.e., septic systems, water wells, ponds) Nene Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None ( one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 PIS 40ots or less <br /> Alt) Q�C YrI MAXIMUM ALLOWABLE B-T-%•E LEVELS (PPM) 1 50 SO 1 50 .3 .3 1. 1 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> NyJ a t/C�i'1'TPN AXIMUM ALLOWABLE TPH LEVELS (PPM) 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 LOT 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1• Are BTX & E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Yas I✓ o I 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 ES F 4071 <br /> T ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> k AHE F -- <br /> kVALUAT,)R <br /> EH 23 80 (UGTWKSH7)\5/9U <br />