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SAN JOAQUIN CbWfY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA-N..�9IYISION <br /> (, UGST WORKSHEET FOR SITE CLOSURE EVALUATION AE 1013170 <br /> AME OF FACILITY Ger, sr�� WEEPS CODEGy. <br /> DRESS Gc/nTANK 10 it <br /> TANK S12E O(IUn UEL TYPE ,y c <br /> 1I. GENERAL S17E HISTORY <br /> ww <br /> Is permit current? es /{ o ermit # - acitity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) N ype of Ta tee? Fbrgl ngl I Dual <br /> III, TANK HISTORY <br /> Jos Tank tested? es Nom` ailed precision test 7 es U vl if yes, give date(S) / <br /> Jos a repair made to the tank system? es ,- o f yes, what was repaired? <br /> Jos repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of faiture/discharge atastrophic long-term leakage verfill known they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received eso epth to Ground Water (f�+r of/Year SL, ;fes verage Annual Precipitation = 4 0-25 <br /> -Site Well(S) hLS1 o umber 8 Type 11 r om ub <br /> S Score s Score S core <br /> istance to Wett(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 5 25-5OL <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown PIresent <br /> verage Annual Precipitation (inches) xxxxxx -10 9 10-25 XXXXXXX 26-4OL <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least I 4ore than <br /> xxxx Hone one one <br /> COLUMN TOTALS»>TOTAL POINTS } 3 + I <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T x E e T x E <br /> T t3o PP''' E =5a QPM MAXIMUM ALLOWABLE B-T-X-E LEVELS (FPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: <br /> SOLINE 1000 100 10 <br /> [MUM ALLOWABLE TPH LEVELS (PPM) <br /> L16 Po 4e/,f TPH- [ESEL 10,000 1000 t0O <br /> OOTNOTES: <br /> ***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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> L Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel), <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 6 E or TPH Concentrations > Alt wable Levels Yes I Vo <br /> 2- Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> F4AKE <br /> WITHESTAFfRECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATIOfiR EVALUATION EFERRQ / 'Lj / p1 ATE CLOSURE LETTER MAILED <br /> F <br /> TOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />