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SAN JOAOUIN C.-4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL,d DIVISION <br /> I' AME OF FACILITY UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> - <br /> GuZi>t�1 — WEEPS CODE rj�S� <br /> 00 RF SS �7UlJ �� ANK ID # <br /> IANK SIZE ,cfSU UEl TYPE <br /> .-.. II. GENERAL SITE HISTORY <br /> Is Permit current? es o ermit <br /> acili ty Status Code oc.Soi(/GV Cont es o <br /> umber of Tanks at facility ge of ianks(if available) <br /> ype of Tank Ceti Fbrgl rgl Dual <br /> III. TANK HISTORY <br /> as Tank tested7 as o ailed precision [est 1 es o <br /> give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired] <br /> as repair done tinder inspection7 es o ere soil samples enelyzed7 es o TXE PH-G PH•0 b/E08 <br /> YPe of failure/discharge a[astroPhic Lmg-term leakage verfill nknown th a r: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Oil Sargtes Received es 1 1 o epth to Ground Vater / <br /> !)i' of/Year verage Annual Precipitation = 40-25 <br /> -Site Wett(s) es o I caber b Type frr I an ub <br /> istance to Well(s) from Tank ft. 5 core S core S core <br /> ft; ft C 0 pts C pts C pts <br /> 0 if O if 0 f <br /> Site Feature - Leaching Potential Analysis R onditlon R and I tion R and ti on <br /> E is met E is met E s met <br /> ininxm Depth to grourdwater from the Soil Sa to (feet)) >100 1-100 25-50\1 <br /> rac[ures in subsurface (applies to foothills or mountain areas) <br /> l0 None Unknown resent <br /> verage Annual Precipitation (inches) <br /> xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. <br /> At leas[ are than <br /> xxxx <br /> More one one <br /> COLUMN TOTALS>>>TOTAL POINTS /� + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS .9 pts or more 41 - 48 pts 40 pts or less <br /> T= 14 Z or L ,.I�/S�7 HAXIMLN ALLOWABLE B LS <br /> -T-%-E LEVE (PPM) 1 50 50 50 .3 .3 X E <br /> 1. 1. NA\3 <br /> ample Result: <br /> 3 10 AX IMUM ALLOWABLE TPN LEVELS (PPM) <br /> ASOLINE 1000 100 <br /> w+ TPN <br /> IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground waterr.)poCm[ial <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. It 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 concert[ra tion of 10 ppm (gasoline) or 100 ppm (dieseU. <br /> STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX S E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> REVIEW EVALUATION - TO BE CCHPLETED BY A SUPERVISOR/SENIOR r� <br /> .ONTREFERRED <br /> RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGAi ION FOR EVALUATION ES 0 <br /> AT / / ATE CLOSURE LETTE(AMVA <br /> EH 23 80 (VGTWKSNT)\5/90 <br />