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f <br /> SAN JOAOUIN COUNTY F SIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIV ?ON 2 <br /> I. UGST 'SHEET FOR SITE CLOSURE EVALUATION `r..� ATE <br /> AME OF FACILITY y�a t' EPS CODE / S <br /> OGRESSj ' -T r `��� — AM( ID X • 1�3s-I�z <br /> LANK SIZE i UEL TYPE I <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 Ifes I 7tf- ermit 0 - C)p� acility Status Code 101 oe.Soit/GW Cont es a <br /> umber of Tanks at facility —�— ge of Tanks(if available} ype of Tank Leel 114brgt mgt I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es I VINO ailed precision test ? es o [f yes, give date(s) <br /> as a repair made to the tank systems es No f yes, what was repaired? <br /> as repair done under Inspection) Ifes o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophie Eong-term leakage verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received eso epth to Grated Water D of/Year b ; verage Armat Precipitation <br /> -Site WeEI(s) es oumber b Type Irr om ub <br /> S Score S Score S core <br /> istance to Wett(s) from Tank it; _f t. ft G 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R condition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> �inimtm Depth to grourdwater from the Soil Saapte (feet) >100 51-100 25-50\1 <br /> raczures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 25-40\2 <br /> an-made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wel(s, pards) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wetls. At least 4ore than <br /> Xxxx None one One <br /> COLUMN TOTALS»­TOTAL POINTS + 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 /> T= <br /> 'Z251' B T X E B T X E <br /> HAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) T 50 50 50 .3 1-3 1. 1. NA\3 <br /> mpte Result: SOLINE1000 100 10 <br /> 'S AXIK24 ALLOWABLE TPR LEVELS (PPM) <br /> TPH IESEL 101000 loco 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination Is present, do not complete the leaching potential <br /> analysis. Cf.*., site Is currently on UGT Contamination List for soil or grotm 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 Levets for STXBE are not applicabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOr41ENDATION/CCNCLUSION <br /> 1. Are 8TX & E or TPH Concentrations > Allowable Levets Yes o <br /> 2. Recommend Site Closure ves <br /> o If Yes, Refer to Site Mitigation for Evaluation <br /> 'I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> oNCUR WITH STAFF RECCHMENDATIOH FOR CLOSURE ES 0 EFERRED TO SITE HITIGATICH FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED y / <br /> SAME OF <br /> :VALUATCR <br /> CH 23 80 (UGTWKSHT)\5/90 <br />