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SAN JOAOUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL R.. DIVISION <br /> L• UGST WORKSHEET FOR SI7E,C[OSURE EVALUATION ATE <br /> AME OF FACILITY L UAC-7) U i• Py I EEPS CODE f X LG7 p <br /> DDRESS i✓ �5� LU C,C, -17 11_1; 00 C I Gr_k,C_Tnoj TANK ID:"# G - 6. <br /> TANK 512E C)()o UEL TYPEo�� <br /> If. GENERAL SITE HISTORY <br /> Is permit current? es a ermit # - acidity Status Code! oc.Soii/Gw Cont es o <br /> umber of Tanks at facility QIP ge of Tanks(if available) ' ype of Tank' teed Fbrgt ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es a ailed precision test ? es 01% If yes, give date(s)' �� <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere sail samples analyzed? es o TXE PH-G PH-D I b/EDB <br /> " x <br /> ype of failure/discharge atastrophic tong-term leakage verfilt nknown ther: ' <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received es o epth to Ground water ef./Year ;�� verage Annual Precipitation <br /> )n-Site WeIL(s) es 140 umber 8 Type Irr am `j ub <br /> S Score S' Score 5 3core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C pts C 5 pts - <br /> 0 if 0 if 0 if- <br /> R condition R 'condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E "s .met 1 <br /> inimun Depth to groundwater from the Soil Sample (feet --- >100 ---- `' 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills/6r,lmount/ainreasS' None Unknown.. 5resent <br /> verage Annual Precipitation (inches) / / xxxx <10 9- 10-25 Kxxxxxx 25-40\2 <br /> an-Made conduits which increase verticaVmigratlon <br /> f Leachate (i.e., septic systems, water wetts, porxls) None Unknown resent <br /> pique site features: Recharge area, coarse said, nearby wells.- At Least 4ore than <br /> xxxx None one 5 one <br /> COLUMN TOTALS>>>TOTAL POINTS v + + <br /> ample Resutt: (B T X OR E) RANGE OF TOTALPOINTS 9 pts or more 41 .,; 48 pts 40 pis or Less <br /> b <br /> g�_ I[QDPpB T X E B JT X E <br /> __ _ -3C- _ __ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 <br /> .3: .3 1. 1. NA\3 <br /> ample Result: ASCLINE 1000 1.00 .10 <br /> AXIMUN ALLOWABLE TPH LEVELS (PPM) <br /> -!�>IP:_P = r0 TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not'cov',Lete 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 O'points. If depth ­5 ft:, do not use table. <br /> \2 If precipitation is > 40 inches, -score 0 points. <br /> \3 Levels for BTX8E are not applicabte at a TPH concentration of 10 ppm (gasot.ine) or 100 ppm (dieset). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es` o If Yes, Refer to Site Mitigation for Evacuation <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 / / ATE CLOSURE'LETTER MAILED / <br /> AME OF <br /> =VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />