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SAN JOAQU`rcOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL fPLALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �. ' (7 <br /> AME OF FACILITYUAIU . d cad- .a Q WEEPS CODE �9 702 <br /> DRESS (0'7 Lf q kqajNAjZ b ANK ID # a <br /> ANK SIZE �� aj� AI UEL TYPE Un IF <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? Fs o JA ermit # O O -j q 7 Q acility Status Code gocl oc.Soi W Cont es o <br /> umber of Tanks at facility 3 ge of Tanks(if available) ype of Tank tee? FbrgL ngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es k o ailed precision test ? es X o I If yes, give date(s)T/ ( q7, <br /> as a repair made to the tank syste es No f yes, what was repaired? I A / Leto', <br /> as repair done under inspection? es o ere soil samples analyzed7 es o TXE PH-G H-D X b/EDB <br /> Type of failure/discharge atastrophic Long-term leakage verfill nknown ther: pl p,,7 11n e— 1pq,/G <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 Water of/Year verage Annual Precipitation = 4 0-25 <br /> 3n-Site Well(s) es I o umber & Type I Irr I om I ub <br /> S Score S Score S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 9 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 9 Unknown resent <br /> verage Annual Precipitation (inches) 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) None 9 Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None 9 one once <br /> COLUMN TOTALS>>>TOTAL POINTS + 75 + L <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 - 48 pts 40 pts or less <br /> KI) - B 1 T X E B T I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> # TPH , ID IESEL 10,000 1 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 /> ,L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not appLicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes o 1 _ <br /> '� <br /> � cct�� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Eva nation c.46 <br /> 5 'TPN- <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR -7-P14_(� 0 , <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 Q <br /> VALUATORp- <br /> EH 23 80 (UGTWKSHT)\5/90 <br />