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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. UGST WORKSREET FOR SITE CLOSURE LVALUATIW ATE <br /> AME OF FACILITY M '7 �� NEEPS CODE <br /> DRESS ��r�r� Ste ' 6 JfANK ID If 1 �5 <br /> IANK SIZE i UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ss <br /> Is permit current? ea I o ermit N - aciLity Status Code oc.Soi l/GW Can[ es o <br /> unxxr of Tanks at facility ' Re of Tutks(if available) f-7 f Type of Teck tact fbrgl not Duel <br /> III. TANK HISTORY <br /> Jas Tank tested? es u o ailed precision test ? as o VIf yes, give date(s) <br /> Jas a repair made to the tank sys Uan7 es No f yes, what woo repo lred? <br /> Jas refnir date under Inspection? as o are soil samples snalyced7 es o ITxE IPM-G PH-D U/E00 <br /> type of fol lure/discharge etastroph is lmB't arm leakage verfill sown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> :oil Samples Received ea N INO <br /> epth to Ground Water vo of/Year /y ;,I D verage Annual Precipitation 4 0.25 <br /> -Site Welt(s) es o X umber 8 Type I trr I ub <br /> 5 core S Score S Core <br /> )istnnce to WeIL(s) from Tank ft; ft; ft C 10 pts C V pts C pts <br /> 0 of 0 If 0 if <br /> R �undi tion R cundit ion R and I t on <br /> Site Feature • Leaching Potential Analysis E is net E is net E is net <br /> Ininun Depth to groundwater frau the Soil Smlple (feet) >100 31.100 - 25-50 1 <br /> -ractures in subsurface (applies to foothills or mountain areas) U None Unknown resent <br /> Average Annual Precipitation (inches) xxxmx 00 9 10.25 Kxxxxxx 26.402 <br /> nn-Made conxA3its which increase vertical migration <br /> ( leachate (i.e., septic systeae, water wells, prods) None n Unknown resent' a14 <br /> nique site features: Recharge area, coarse soil, nearby wells. At Leas[ 40re than <br /> xxxx None 0"a. we <br /> ` <br /> Cl �" 1 <br /> COLUMN TOTALS»>TOTAL POINTS + yI I J? ? <br /> mlpte Result: (e T X OR E) RANGE OF 701AL POINTS .9 pts or more 41 - 48 pig 40 pts or less <br /> r N E <br /> X ,LgMAXI Xl1X ALLOWAOLE B•T-%•E LEVELS (PPM) 1 50 50 50 .3 .3 I. 1. NAL <br /> maple Result: �o Y -ASOLIME 1000 100 10 <br /> AXI MUX ALLOWABLE TPH LEVELS (PPM) <br /> PN IESEL 10,000 1000 100 <br /> OUINOTE S: <br /> ...If doeuiented soil and/or ground water corltmnirNltion is present, do not eaq)lete the leaching potential <br /> analysis. (I.e., site Is currently on UGI Contamination List for soil or ground water.) <br /> 11 If depth is > S ft. and < 25 it., score 0 points. It depth <_S ft., do not use table. <br /> L2 If prec ipdtation is > 40 1rches, score 0 points. <br /> It Levels for BTXBE are not applicable et a TPI( concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BT% L E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recomaend 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 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF 1 <br /> :VALUATOR <br /> FH 2.1 80 (UGTWKSHI)\5/90 <br />