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SAN JOAWIN0­JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HER DIVISION <br /> !, UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY O ECORD ID ////;;;; r� <br /> ADDRESS o I }yLJ ANK ID # 3? - //5O-05— <br /> TANK SIZE ! QQQ UEL TYPE D, e <br /> !I. GENERAL SITE HISTORY <br /> is permit current7 es o 1 VlPermit # - aciliry Status Code x-Soi L/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank teeL I Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? es o ailed precision test ? es a If yes, give date(s) <br /> Was a repair made to the tank system? es No f yes, chat was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic Lag-term Leakage verfill noun I ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water A of/Year 8 verage Annual Precipitation = 4 0-25 <br /> On-Site WeLI(s) es o umber 8 Type 1 11 r I 1IM ub <br /> 5 core S core S core <br /> istance to WeLL(S) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 1f 0 f <br /> R ondition R ondition R ordition <br /> V. 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 a -100 1-100 I © 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) l None Unknown Present <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxmx 26-40L <br /> an-Made conduits which increase vertical migration <br /> I f leachate (i.e., septic systems, water wells, ponds) / Q None Unknown resent <br /> nique site features: Recharge area, coarse soil, or wells. At least ore than <br /> (Muncipal=>2000 ft; domestic=-500 ft; irr/agricultural=present) txxxxx None one one <br /> TK s T- J�0 I-"i Ny <br /> C as x COLUMN TOTALS>--TOTAL POINTS <br /> ample Result: (B X OR,E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts- 40 pts or less <br /> TK IL l! E6= .6 <br /> �[ — • 3 B I T X E B T X E <br /> /- MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAi <br /> _rX a%e oR es U 10 <br /> DmyyAXIMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 <br /> K 11 IESEL 10,000 1000 100 <br /> OOTNOTES: If documented soil and/or ground water contamination is present, do not complete the Leaohi <br /> analysis. (i-e., site is currently on UGT Contamination List for soil or ground water.) <br /> If depth is > 5 ft- and < 25 ft., score 0 points- If depth c5 ft-, do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \33 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel), <br /> VL STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes M. <br /> L� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation xt 2 1 7-/ 7 <br /> v11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR u <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />