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SAN JOAQUIN C ( PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAD[VISION ATE 3 <br /> 1 UGST WCRKSHEET FOR S1 TE CLOSURE EVALUATION <br /> EEPS CODE <br /> AME OF FACILITY [ <br /> DDRESSANK 1D # <br /> IANK 512E <br /> 2Li� <br /> L TYPE <br /> f[. GENERAL SITE HISTORY *• / <br /> is permit current7 es o ermit # - <br /> acitity Status Cade oc.SaillGSl Cant es ✓ o <br /> y e of Tanks(if available) n rcl�Cc ype of Tank tee? Fbrgl ngl Dual <br /> tnmber of Tanks at facility 4 <br /> 111. TANK HISTORY <br /> ms Tank tested7 es o ailed precisi test ? es 0 If yes, give date(s) <br /> as a repair r made to the tank system? es No f yes, what was repaired? '`i���"U 3 '3cw 0,,-j toil o�T � ,1Z7ik_N <br /> C <br /> as repair done under inspection? es o ere soil samples analyzed? es 0 TXE PH-G PH D b/EDB <br /> ype of failure/dischargtastr0plhic long-term leakage verfitt nknown ther: <br /> e a <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year <br /> verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber & Type Irr om ub <br /> S care S care S core <br /> istance to dell{s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if O if 0 f <br /> R ondition R ondition R andition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample {feet)2 Q' f� %�� <br /> :100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> Ian-Made conduits which increase vertical migration Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) None <br /> At least 'ore than <br /> pique site features: Recharge area, coarse soil, nearby wells. one one <br /> xxxx None <br /> COLUMN TOTALS»>TOTAL POINTS <br /> # J_ <br /> awte�R,esult; (B TOR E) P RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> dZ(o ©2� •o�Z f�ZS + 8 T X E B T X E <br /> N'•P .0718 -b05MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ASOLINE 1000 100 10 <br /> ample Result: <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH IESEL 10,000 lDOO <br /> FOOTNOTES: ***If documented soil and/or ground water c ination is present, do not complete the teaching potential <br /> analysis. (i.e., site is Curren y on UGT Contamination List for soil or ground water,) <br /> \1 If depth is > 5 ft. and < 25 ft., sca e 0 points. If depth <=5 ft. do not use table. <br /> \2 If precipitation is > 40 inches, Sc0 e 0 points, � �� ���^— � diesel). <br /> \3 Levels for BTX&E are not appticable a TPH con ion o s0line { <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > All able Levels Yes 0 <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO 8E CCMPLETED BY A SUPERVISOR/SENIOR <br /> ---------------- <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 /> DAME OF <br /> ;VALUATOR <br /> EH 23 -80 (UGTWKSHT)\5/90 <br />