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SAN JOAQUIN CO PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAODIVISION <br /> f. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE o gF(� <br /> AME OF FACILITY ���- WEEPS CODE <br /> DDRESS 0� a / f�yj TANK !0 # <br /> ANK 512E UEL TYPE <br /> II . GENERAL SITE HISTORY <br /> Is permit current? es IN01 <br /> ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT ype of Tank teel FbrglI IS ngl Dual <br /> 111. TANK HISTORY <br /> 'os Tank tested? es iNo <br /> ailed precision test ? es 0 If yes, give date(s) <br /> as a repair made to the tank system? Yes No ITf yes, what was repaired? <br /> ns repair done under inspection? es No ere soil samples analyzed? 1Yes to 1 1, <br /> TXE ITPH-G PH-0 b/EDB <br /> vpe of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANAL"SIS) <br /> Soil Samples Received es o epth to Ground slater of/Year ; ( verage Annual Precipitation = 4 10-25 <br /> n-Site Well s) es o unuer 8 Ty--;-F7, <br /> e [rr cm uu <br /> S Score S Scare S Score <br /> Distance to WeIL(S) from Tank ft; ft; ft C 0 pts 9 pts C 5 pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)/P—O--36 >100 I 1-100 125-50\1 <br /> �ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage A mual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> ( leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more + 41 48 pts 40 pts or less <br /> S I T X E 8 T X _ <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> `lthy-. MAXIMUM 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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. 1f depth —5 ft., do not use table. <br /> \2 1f 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 /> V1. STAFF RECOMMENDATION/CONCLUSION 1, Are BTX 3 E or TPM Concentrations > Allowable Levels Yes oL-- bod � l <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation + <br /> J11, REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> -CNCUR '.11TH STAFF RECOMMENDATION FCR ESIES �t0 I I?EFERRED TO SITE MITIGATION FOR EVALUATION �ES �40 <br /> ATE REFERRED / �1; / �( ATE CLOSURE LETTER MAILED <br /> AME OF l/ <br /> :'VALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br /> 7 2 9 3,0 <br />