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SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL•LTH DIVISION �'1 Q <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE —d if—f <br /> AME OF FACILITY F 7 WEEPS CODE / -7 3 <br /> DRESS L{.s �� � Q,�, ANK ID u 13 q-17&3- O�l-- <br /> ANK SIZE $ U�� UEL TYPE 4Fa <br /> 11. GENERAL SITE HISTORY <br /> Is perm, current? es o ermit # - aciLity Status Code oc.Soi L/GW Cont as <br /> Fr�ffi, �� o <br /> umber of Tanks at facility ge of Tanks(if available) I (, r,1 ype'of Tank teel lvlFbrgL ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es I V10 ailed precision test 7 es o If yes, give date(s) ' // 7 Ifo / / <br /> Jas a repair made to the tank system? as No f yes, what was repaired? rote <br /> as repair done under inspection? es 4b ere soil samples analyzed? es o TXE 1,PH-G I PH-D /EDB <br /> Type of failure/discharge atastrophic long-term leakage verfitt nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 0 epth to Ground Water of/Year verage Annual PrecipitationF25-50� <br /> -Site WeIL(s) es 0 oumber 8 Type Irr an ubs core S core S istance to Wetl(s) from Tank -Z,5-ft, ft; ft C 0 pts C pts C 0 if 0 if 0 R ondition R ondition R V. Site Fea[ure - Leaching Potential Analysis E is inet E is nN:t E inimum Depth to groundwater from the Soil Sample (feet) >100 (� 1-100 ractures in subsurface (applies to foothills or mountain areas) , None Unknown verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxan-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown <br /> pique site features: Recharge area, coarse soil, nearby wells. /) At Least ore than <br /> xxxx None 7one one <br /> COLUMN TOTALS»>TOTAL POINTS 110 ♦ A7 <br /> ammppl�,e/Result: <br /> y�(B TyX OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> O It//rf Z /9�1 lzio <br /> NI-) MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. NAL3 <br /> ample Resul : ) ASOLINE 1000 100 10 <br /> K1�J IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 /> 11, If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 1 If precipitation is > 40 inches, score 0 points. <br /> .\3 for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION , <br /> 1. Are BTX 8 E or TPN Concentrati ons > ALL otble Levels Yes o <br /> I2. Recommend Site Closure Yes I No I �,��If Yes, Refer to Site Mitigation for Evaluation SetJ /altk' —� <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 />