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SAN JOAWIN�TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE�H DIVISION ATE <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION p� <br /> qME OF FACILITY ev.�j�,'r' LJS��u-✓LV1 ('() C WEEPS CODE <br /> DDRESS I =- cb N . schobI LQc ( ANK ID # 3q_238"6-01 <br /> TANK SIZE 27 G,Q UEL TYPE I C�, 5 <br /> 11. GENERAL SITE HISTORY .* <br /> Is permit current? es IN <br /> o ermit # acility status Code 50 IDoc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) 4 9 y5 ype of Tank teel rgl ngL Dual <br /> 111. TANK HISTORY 1Y�5'F4LCl4 <br /> rQlnnn� •l6 <br /> as Tank tested? IYes I IN01 ailed precision test ? es o f yes, give <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? 6s o ere soil samples analyzed? es o TXE -G 'D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfiLL nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received es o epth to Ground Wa[ '5G lAverage Annual Precipitation A= 4 10-25 <br /> •site Wells) es o umber 8 Type ITT om ub <br /> S Score 5 Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R ondit ion 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) 354- 2-- >100 1-100 5 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) ' p None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10.25 xxxxxxA 26-40\2 <br /> nn•Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None �r1 one �j one <br /> COLUMN TOTALS>>>TOTAL POINTS 6O * -212 i 4Z <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 025;Pf;,r , G T % I E B T X E <br /> U MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) 1 50 1 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: PIESEL <br /> 1000 100 10 <br /> A%IMUM ALLOWABLE TPN LEVELS (PPM) <br /> N p (Pf""� TPH 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 not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION O Q ✓4� tl� <br /> 1. Are BTX 8 E or TPH Concentrations Allowable Levels Yes o <br /> 2. Recommend Site Closure es 10Q If Yes, Refer to Site Mitigatiai for Evaluation <br /> VII. REVIEW EVALUATION • TO BE CCMPLETED 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 `J <br /> EH 29 80 <br />