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SAN JOAOUIN4.4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HES, DIVISION <br /> !. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I ECORD 1D -1.� 1 1 <br /> ODRESS 13© I/. GF((SL(h/�/ ID # F -2311 <br /> [/( c © / <br /> TANK SIZE 1 .94000 UEL TYPE _LANK,(,e <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code cc.Soil/GW Cant es o <br /> tmber of Tanks at facility ge of Tank(if available) ype of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> a ailed precision test ? es oI If yes, give date(s) <br /> as Tank tested? es <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> zs repair done under inspection? eso ere soil samples analyzed? es o TXE PX-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage I verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es o epth to Grorard Nater of/Year verage Annual Precipitation = 4 0-25 <br /> r,-Site Wells) es o umber & Type I Irr cm ub <br /> S core S core 5 core <br /> istance to WeLL(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 4 <br /> 1 0 if 0 f <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)30—42f) >100 1-100 25-50L <br /> �ractures in subsurface (applies cc foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xmxmx 26-40L <br /> an-Made conduits which increase vertical migration <br /> If leachate (i.e., septic systems, water wells, ponds) L, None Unknown resent <br /> nicue site features: Recharge area, coarse soil, or welts. l/ At least are than <br /> [Muncipat=>2000 ft; domestic=>500 ft; irr/agricultural=present] Xxxx None one one <br /> 7K = -p• X=3. '� d <br /> 61 3�3 COLUMN TOTALS>>>TOTAL POINTS , Q a <br /> lj� j E) RANGE OF TOTAL POINTS 9 pts or more I 41 - 48 pts 40 pts or less <br /> TK y 0 Zh' B T X E B TXE/ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. Ei NASamplSOLINE 1000 100 10oc <br /> AXIMUM ALLOWABLE TPH LEEVELS (PPM) <br /> TESEL 10,000 1000 �\ 100 <br /> OOTNOTES: *"!f documented soil and/or ground water contamination is present, do not complete the Lea <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. If depth <=5 ft., do not use table. <br /> \22 If precipitation is > 40 inches, score 0 points. <br /> \33 Levels for BTX&E are not applicable at a TPH concentration of 10 Fpm (gasoline) or 100 ppm (diesel). <br /> VT. STAFF RECOMMENDATION/CONCLUSION P�� ,� .-„ntz„ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes56-1 1 C <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for EvaLuationN ,6 3-1747 <br /> 7 7 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ELE <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED I / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 '4g'6 <br /> r " <br /> I ucol �����r�o�cn� �S foc /C <br />