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NTY PUBLIC <br /> 1 SAN JOAOUIN COUGST WORKSHEETAFOR SITElCLOSURElEVALUATIONHE DIVISION ATE <br /> AME OF FACILITY STCO3 `-�� EEPS CODE r 7 <br /> DDRESS 15 ANK ID # <br /> TANK SIZEUEL TYPE ( 'Iovgo u V <br /> z — 1000�x( ulee4 m l <br /> 11. GENERAL SITE HISTORY 4A _ D <br /> Is permit current? es o ermit # acility Status Code oc.Soit/GW Cont os01 � o <br /> umber of Tanks at facility he of Tanks(if available) ype of Tank teal Fbrgl I Isngi. I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es IN01 ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? IYes No 1 11f yes, what was repaired7 <br /> Ons repair done under inspection? es o ere soil samples analyzed? real to T%E PH•G PN-D b/EDD <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es IX o epth to Ground Nater Ithoof/Year I WOU verage Annual Precipitation = 4 IO.25 <br /> )n-Site Wetl(s) IYes o N umber 8 Type I Irr om ub <br /> S Score S core S Score <br /> !stance to Wells) from Tank ft; `-> Z7 ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 1f 0 if <br /> R ondition R ondi tion 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 Sade (feet) >100 1-100 '-7 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Iy0 r1 verage Annual Precipitation (inches) KXXXXX <10 9 10.25 Kxxxxxx 26-40\2 <br /> Irl �ll an-Made conduits which increase vertical migration ID <br /> f leachate (i.e., septic systems, water wells, ponds) None -� Unknown resent <br /> A04" Inique site features: Recharge area, coarse soil, nearby wells. Cj j48 <br /> t ore than <br /> xxxxx Nonee one <br /> COLUMN TOTALS>»TOTAL POINTS ' <br /> Semple�ReLsult: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or mo1d, <br /> 40 ptsorless0- r�'9L B T X BMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 .3 NA\3 <br /> 'a le Result ltx 0„ �D ASOIiNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> Q�'-- (D 17L TPH IESEL. 10,0001000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, 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 <e5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Reconnend Site Closure as t90 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 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> ER 29 80 <br />