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SAN JOAQ000UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ALTN DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION _ <br /> AME OF FACILITY P O / `//q0 WEEPS CODE ATE C3- l7� a . <br /> DRESS / -A(� O t T/1 / q� O J <br /> �C(/I'LQ� ANK FD k 3 / <br /> ANK SIZE / O�D UEL TYPE <br /> w� <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit N - q •* <br /> ecility Status Code / ac.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) <br /> ype of Tank teal Fbrgl npl Dual <br /> III. TANK HISTORY <br /> as Tank tested? as V o ailed precision test es <br /> o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? e o <br /> TXE PH-C PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ' cher: <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 Zr 1 of/Year <br /> J(, �: verage Annual Precipitation = 4 0.25 <br /> Site Wells) es I o I umber 8 Type irr [ion I b <br /> istance to Well(S) from TankftS core S core S core <br /> ; ft; ft P OC '0 pts C is C <br /> pts <br /> 0 if 0 if <br /> Site Feature - Leaching Potential Analysis R ondltl an R onditlon R ondition <br /> E is met E is met E s net <br /> inimum Depth to groundwater from the Soil Sanple (feet) <br /> ,r !_ >100 1-100 2�— 25-501 <br /> ractures in subsurface (applies to foothills or mountain areas) p <br /> None 1 Unknown resent <br /> verage Amual Precipitation (inches) <br /> xxxxx <10 9 10-25 xxxxxx 26-40L <br /> an•Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) f O <br /> None Unknown resent <br /> nique Site features: Recharge area, coarse soil, nearby wells. <br /> At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS I bt 7 * S Z/ <br /> ample Result: IS T K OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 is <br /> c • 1 5_5 J fA^ P 40 pts or less <br /> l �14'' ig B T X E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAJ3 <br /> ample Result: <br /> A%IMUM ALLOWABLE TPN LEVELS (PPM) ASOLINE 1000 100 10 <br /> TPH IESEL 10,000 <br /> 1000 100 <br /> OOTNOTES: •ttlf documented soil and/or ground water contamination is present, do not coy tete the Icachin potential <br /> analysis. (i.e., site is currently on UGT Centamina tion List for soil or ground water,) <br /> 1 If depth is > 5 f[. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> 13, Levels for BT%8E are not applicable at a TPH concentration of 10 Ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> /1 GCI Y a fi'�w Lv 17lu�yLcvcaAQa . Q� , <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Reconmend Site Closure es o tion � ��—p- ,/wa,(ffzpLW..tro� <br /> If Yes, Refer to Site Mitigation for Evaluation �(�CA- C � <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR R W <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)\5/90 <br />