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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> i, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY NU _ L AVE (rE GQ; 2N G WEEPS CODE <br /> DRESS 1(XO Z> E - FRD(JT TANK ID <br /> ANK SIZE pU D UEL TYPE V L - <br /> 11. <br /> GENERAL SITE HISTORY <br /> Is permit current? .es 0 ermit 1! - aciLity Status Code L 3 oc.Soit/GW Cont es a <br /> umber of Tanks at facility r ge of Tanks(if available) IType of Tank teal Fbrgt I IS-9t Dual <br /> I11. TANK HISTORY <br /> Jos Tank tested? es X a ailed precision test 7 as 0 If yes, give date(s) $ /u /94 <br /> as a repair made to the tank system? Yes No f yes, whatkwas repaired? <br /> Jos repair done under inspection? 40 dere soil samples analyzed? es 0 TXE. PH-C PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term Leakage LlverfiLt lx�-known ther: . <br /> i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es K o epth to Ground Water v� of/Year 5 vJ. verage Annual Precipitation = 4 0-25 <br /> -site Wetl(s) IYes o umber & Type lrr I om I ub <br /> S 3core S Score. 5 core <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O 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 �I <br /> inimxam Depth to groundwater from the Soil Seapte (feet) >100 1-100 p 25-5011 <br /> Fractures in subsurface (applies t0 foothills or mountain areas) None (—k Unknown 5resent <br /> verage Annual Precipitation (inches), KXXXXX <l0 91 10-25 xxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> Df Leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse'soil, nearby wells., At least ore than <br /> xxxx None CA one one <br /> COLUMN TOTALS»>TOTAL POINTSi. + <br /> empt 3 Re silt: (B��X OR7 E�� RANGE OF TOTAL POINTS 9 pts or more 47 -:48 pts t 40 pts or less <br /> z <br /> vov PP"' B T X E B T X E <br /> �. i i <br /> x` i�yo�i"'+ MAXIMUM ALLOWABLE B-T-X-E LEVELS;(PPM) 1 50 50 50 .3 .3 1. 1. NA <br /> Sample Result: ASOLtNE 1000 100 10 <br /> 4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> _TPH IESEL 10,000 1000 -- 100 <br /> FOOTNOTES: ***If documented snit and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently ofi'UGT Contamination List for soil or ground water.) <br /> \1 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 /> 13 Levels for BTX&E are not applicable at a.TPH.-concentration of 10 ppm/ (gasoline) or. 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSIONAi'_ / 4 01,4 -Ar 1ur4�C,^ �t/ciCUer�+C17 <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes a <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evatuation <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)S5/40 <br />