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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION o <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE c;,_ O - <br /> AME OF FACILITYWel Sl(\(]� 15� 1 1✓lL. WEEPS CODE <br /> ADDRESS I 1 <br /> b V"Q5� �v ` ANK 10 N <br /> TANK SIZE 5 UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit M - acility Status Cotle cc.Soil/GW Con es o <br /> umber of Tanks at facility Be of Tanks(if available) IType of Tank tee rbr gl ngl Dual <br /> 111. TANK HISTORY r 5, �as <br /> - <br /> as Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection7 es o ere soil samples analyzed? ITas o TXE PH-G I PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfiLI nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es ✓ o epth to Ground WaterLo of/Year verage Annual Precipitation = 4 0.25 <br /> -Site Welts) es ✓ o umber 8 Type Irr om b <br /> -- S Score 5 Score S care <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> O if 0 if 0 f <br /> R ondition R condition R ondition <br /> — V. Site Feature - Leaching Potential Ana Lysis E is net E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown Dresent <br /> verage Annual Precipitation (inches) xxax <10 9 10-25 xxxxxxx 26-40 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 5 resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At leastore than <br /> - - x"A None one 5 one <br /> COLUMN TOTALS»>TOTAL POINTS Ip . I + I(J <br /> ample Result: (B i X OR E) RANGE OF TOTAL POINTS 9 pts or more (441 - 48 pts 40 pts or Less <br /> R>= .oy3 3C4 <br /> i I�Z B 1 T XE B T X E <br /> MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: SOL1000 1000 100 10 <br /> .� AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH f. IESEL 10,000 1000 100 <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 /> ,2 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTXBE are not applicable at a TPH concentration of X10 ppm (gasoline) or 100ppa (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION tl Vy: Ai-Axe. of (err&kn <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o YbXai oLaer: eci <br /> 2. Recommend Site Closure es j o If Yes, Refer to Site Mitigation for EvaLua[ on <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <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 L <br /> VALUATOR C <br /> EH 23 80 (UGTWKSHT)15r9n <br />