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SAN JOAQUIN tiuWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA i�H DIVISION <br /> i UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE '.3 •� <br /> AME OF FACILITYL WEEPS CODE CT-S <br /> DDRESS 3 L ��w 1� (fTANK ID # <br /> 3 5'-Z�2S-D <br /> TANK SIZE gO UEL TYPE <br /> 11. GENERAL SITE HISTORY 2— <br /> is <br /> is permit current? es o rmit # lFacitity Status Code ,5( oc.Soil/GW C,<Fe,D Jo <br /> umber of Tanks at facility kge of Tanks(if available) ype of Tank teel FbrgtI IS ngl Dual <br /> ill. TANK HISTORY t ✓\G -& <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(S) / <br /> as a repair made to the tank system? 1Yes No I 11f yes, what was repaired? <br /> ns repair done under inspection? Ifes I No-1 ere soil samples analyzed? es Jo I TXE PH-G I IT PH-D I 1Pb/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown Cher: <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 1Y <br /> es o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> Dn-Site WeIE(s) es o umber & Type irr om ub <br /> S core s core s Score <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C 5 pts <br /> 0 if o if 0 if <br /> R ondition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 45-S s 3;� >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) to None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None 9 Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS 2 ) 4 Z <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- NDO5pPr+o <br /> I' I E ND @g ,� B 7 X JE BE X E <br /> 7 0 D '�a �r"\ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000100 10 <br /> AXIMU14 ALLOWABLE TPN LEVELS (PPM) <br /> (0-0 TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 /> \1 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 /> \3 Levels for BTX&E are not applicable�atja TPH concentration of 10 ppm (gasoline) or 100 ppn (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> l(p wt Ii Z.. b 1.ck lO rAl�EriZG <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes Jo .ID ppm I/'s P+LLL °✓4�lOa✓1LCr2 <br /> .4+ 12+vnz c-kIorOe "Q <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation ppm <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 1, <br /> 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />