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SAN JOAQUINaTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H* DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3 ,(G , QZ <br /> ANE OF FACILyITY�1 c J"a "'W `DMrvllS5KV-)eV <br /> 1-5 EE PS <br /> CODE ,Lq ILI MI5 l <br /> %ODRESS 1 kc,1't L ✓Gvl v 1 1'�l.O t'C 4'� B lud kv", CCL1 ANK 10 # '✓ 1. I LI L{rj— (J2- <br /> ANK SIZE bn.11� UEL TYPE W W <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code FJ ( oc.Soil/GW Con 0s - o <br /> umber of Tanks at facility 3 ge of Tanks(if available) L)VkK YPe of Tank reel/ Fbrgl ngl/ Dual <br /> 111. TANK HISTORY <br /> ,as Tank tested? es o ailed precision test ? es o I If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? es 10 TXE PH-G PH- <br /> Type of failure/discharge atastrophic long-term leakage verfill nk own Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received esly o epth to Ground water 20 of/Year IC& verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) IT <br /> es o umber 8 Type Irr em I ub <br /> S Store S Score S 3core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondi tion <br /> V. Site Feature . Leaching Potential Analysis - E is met E is met E is met <br /> ininxm Depth to groundwater from the Soil Sample (feet) nb_ lU= ly >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 /> nn-Made conduits which increase vertical migration <br /> 1 leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None 2 one lone <br /> COLUMN TOTALS>>>TOTAL POINTS l� 3� U 3L <br /> angle Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B T I X E <br /> BT MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 'POU TPH 1,,, IE SEL 1 10,000 1000 100 <br /> FOOTNOTES: -**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-. 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 B110X l"gkc-ftd <br /> 1, Are BTX 8 E or TPN Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure If <br /> es I a I If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION . TO BE C011PLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / �<� / GI :!_ ATE CLOSURE LETTER MAILED <br /> AME OF �� .` L4 <br /> :VALUATOR I ' <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />