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SAN JOAQUIN*TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H� DIVISION <br /> 1. wGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I S5LV\ �U �Xj I.:,OMMLss S EEPS CODE p lgq,5- <br /> DDRESS 39Q_ 50 r �.l� 1 `v � _I( ,J,- I W '�'`(A✓l.Tt-.CL9 ANK ID # 3l— t((Q5_(0j <br /> TANK SIZE [WU UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? eso ermit # acility Status Code 151 oc.Soil/GW Cont os o <br /> umber of Tanks at facility 3 ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> ,is Tank tested? es o ailed precision test 7 as o If yes, give date(s) <br /> as a repair made to the tank system? es No ITf yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? as 10 I TXE I /EDG <br /> ype 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 ANALYSIS) <br /> oil Samples Received es o epth to Ground Water 24,f/Yea ; 6L verage Annual Precipitation = 4 10.25 <br /> -site Wells) as o umber 8 Type Irr I am I ub <br /> S Score S core S core <br /> istance to Weli(s) from Tank ft; ft; ft 10 pts C pts C pts <br /> •0 if 0 if 0 f <br /> R onditi on R ondition 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) Jd_(Dc (QI >100 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 11 <br /> Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 KXXXXXX 26.40\2 <br /> an-Made conduits which increase vertical migration Q <br /> f leachate (i.e., septic systems, water wells, ponds) None 1 Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> xxxx None one one <br /> COLUMN TOTAL S>»TOTAL POINTS U t 3f/J * 3tp <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> ND 2 pCm B T X E B T X E <br /> e+TKE 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 /> �� AXIMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH,pp n IESEL 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 /> V1. STAFF RECOMMENDATION/CONCLUSION G 1p UL�Z ?)TM be4ecflari L(LLIKUlk�5 tto IL h <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 17o �)Yl- V <br /> 2. Recommend Site Closure es I 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 ITEFERRED TO SITE MITIGATION FOR EVALUATION ES T_-14 0 <br /> ATE REFERRED 3 ATE CLOSURE LETTER MAILED <br /> AME OF / <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />