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SAN JOAQUIN CCUNAPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH•ISION n <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> NAME OF FACILITY EEPS CODE 2eq <br /> DO RE SS / /,5— <br /> ^ 7/'C� /32 1,Jdt A N K 10 i1 - 0-23 <br /> TANK SIZE I C5(jo <br /> UEL TYPE �L,yl lG .o <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es II0 ermit M acility Status Code oc.Soi /GWCont les o <br /> umber of Tanks at facility Be of Tanks(If available) �r1 /, ype of Tank tee? Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank testedt es I INO <br /> ailed precisim test es If yes, give date(s)T/ <br /> as a repair made to the tank system? es No 14f yes, what was repaired? <br /> as repair time under inspection? es11 ere soil samples analyzed? 1Y <br /> es o I TXE I PH-G I Ir <br /> PH-D I IPb/EDB <br /> Type of failure/discharge atastrophic lmg•term leakage verfill nkmwnI lo cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es V <br /> epth to Ground Water 1/0/ of/Year 8(o verage Annual Precipitation = 4 0-25 <br /> i-Site Well(s) as o umber 8 Type Irr an ub <br /> S Score S Score S 3core <br /> istance to Well(s) from Tank A ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R and1tion R condition R ordI tion <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimtm Depth to groundwater from the Soil Sample (feet) �p% g ;Z' >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> %verage Annual Precipitation (inches) KXXxxX <10 9 10-25 xxxxxxx 26-40\2 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i-e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least tore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> PfM <br /> Il B T % E R T X E <br /> X C(�Posf{ )),Z.%LPA� MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> TPN D a <br /> 16"M A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ...If documented soil and/or ground water cmtamina tion is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Cont ami ration 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION a to t0 nn <br /> 1. Are BTX $ E or TPH Concentrations > Alt able Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigatim for Evatuatim V : ^^ X= 12 lr M <br /> E= I m prM '(P4-6 :-- <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR T. 3.?� (y�,r LedA s ,IZ <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER HAILED <br /> LAME OF <br /> :VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />