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SAN JOAQU 'tJUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL TE LTH DIVISION [� <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY R G G , 1 ! S ECORD ID A 3 <br /> OGRESS .3!T /� f/7.` 1:311"d, L ARK ID # „3 <br /> ANK SIZE �Q_ Q��1 UEL TYPE iCI�I[. Nc Li- T V <br /> GC 4- <br /> 11. <br /> II. GENERAL SITE HISTORY <br /> Is permit current? as o ermit # 3 - % y aciLity Status Code L'1 ' ac.Sofl/GW Cant es o <br /> umber of Tanks at facility ge of Tank(if available) P ype of Tank teen Fbrgl ngl I Dual <br /> III. TANK HISTORY &-I,'It .Q..' '70 <br /> as Tank tested? es o I ailed precision test ? as o If yes, give date(s) / / <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspecti on7 es 40 ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Lang-term leakage I 13verfilt noun I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received tea o epth to Ground Water ® of/Year D& verage Amual Precipitation = 4 0-25 <br /> On-Site Well(s) es o umber & Type Irr cm ub <br /> 5 Score S Score S Score <br /> istance to WeM s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition 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) ®—q 5 >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) 10 1 None Unknown oresent <br /> verage Annual Precipitation'(inches) Xmx <10 9 10-25 xmxxxx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> mime site features: Recharge area, coarse soil, or wells. At Least 4ore than <br /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] axro x None one one <br /> COLUMN TOTALS»>TOTAL POINTS V - a i D <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts pts or less <br /> 8 T % I E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1.- 1. -1 NAL <br /> ample Result: ASOLINE 1000 100 - 10 <br /> AX IMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: --If documented soil and/or ground water contamination is present, do not complete the thing potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground we <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BT)&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluation on <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/LEAD SENIOR —`+'-- <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)%5/94 <br />