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SAN JOAOUIN�TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H� DIVISION p <br /> 1, UG/nST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3-(0 , f Z <br /> AME OF FACILITY Sccy\5� U((1. l�1al� Crj(nmIsSI&-jeF'-5 EEPS CODE ILA q5 <br /> DDRESS 3 2 W� rftga ' f\-BI U ANK ID p <br /> TANK SIZE j UEL TYPE <br /> it. GENERAL SITE HISTORY <br /> Is permit current? Fes o ermit If acility Status Cod, 1 j' oc.Soil/GLI Cont eso <br /> umber of Tanks at facility Be of Tanks(if available) �ri1L ype of Tank teal Fbrgl ngl ual <br /> III. TANK HISTORY <br /> STs Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired7 <br /> ns repair done under inspection? eso ere soil samples analyzed? es to I TXE J�JPH-G I PH•D b/E00 <br /> Type of failure/discharge atastrophic long-term leakageverfill I nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water Z U of/Year l ;n veroge Annual Precipitation = 4 10.25 <br /> -Site Well(s) es o umber & Type Irr I am I ub <br /> S Score 5 core S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 1f 0 -f <br /> R condition R ondition R ondition <br /> i. Site Feature - Leaching Potential Analysis E is met E is met E -s met <br /> inimum Depth to groundwater from the Soil Sample (feet) DO- fO.Cjr q,5 >100 1.100 O 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None GUnknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26.40\2 <br /> an-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 /> Xxx% None one one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> * <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS9 pts Or more 41 48 pts 40 pts or less <br /> N� j7p✓YJ B 1 T X E 8 T X E <br /> i MAXIMUM ALLOWABLE 0•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> A%IMUM ALLOWABLE TPN LEVELS (PPM) <br /> No to TPH )Y1 IE-SEL <br /> 1000 100 <br /> FOOTNOTES: ***If docunented soil and/or ground water contamination is present, do not canplete 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 STXBE are riot applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 3q,L((LL5—a <br /> 1. Arc BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII, REVIEW EVALUATION • TO BE COMPLETED BY'A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / �Lj / Y ATE CLOSURE LETTER MAILED <br /> AME OF — <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />