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SAN JOACUIN CTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL REAL VISION <br /> !. UCST WORKSHEET FOR SITE CLOSURE ATE ., ,( <br /> OF FACILITY _ +, . EPS CODE <br /> KESS '�� �( AMK 10 1t <br /> I1. GENERAL SITE HISTORY UEL TYPE <br /> s permit axrent? eso ermit ti - acility Status Code oc.Sofl/GV Cant as o <br /> r of Tanks at facility Be of Tanks(if available) ype of Tank teel brRt l Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test ? es o it yes, give dates) <br /> As a repeir wade to the tank system? es No f yes, what was repairew <br /> Jos repair done under Inspection? es 4o re soil samples analyzed?Ires I o I PTXE I PH-G I PN-D EDB <br /> ype of failure/discharge I tastrophic tang-tern leakage verfitL ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> I <br /> t Samples Received es o th to Ground Vater of/Tear verage Annual Precipitation ■ 4 0-25 <br /> Site Vett(s) es V o r L Type rr <br /> S re S core S are <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 f <br /> R anrlition R audition R ondition <br /> ri <br /> te Feature - Leaching Potential Analysis E s wet E is wet E s met <br /> w Depth to groundwater from the Soil Sample (feet) /(� >100 1.100 25-5011_ms in subsurface (applies to foothills or mountain areas) Mone Unknown resent <br /> e Annuat Precipitation (inches) <10 9 10-25 26.40 <br /> da conduits which increase vertical migration <br /> hate (i.e., septic systems, water welts, ponds) 1 Mane Unknown resent- <br /> iqua site features: Recharge area, coarse soil, nearby wells. (,} At least 4ore than <br /> KXXXXX NOW GG��—/ one one <br /> COLUMN TOTALS>»TOTAL POINTS t p�-� ♦ O <br /> , 47MM-- <br /> Semple Result: (B T X OR E) RANGE Of TOTAL POINTS 9 pts or Bare4r---48 pts 40 pts or less <br /> 8-.�3Z xz.iS7 <br /> B T X E B T JX. ENAXIMUl1 ALLOWABLE B-T-X-E LEVELS (PPM) 1 SO 50 50 .33 11. NAIL <br /> ;empt* Result: INE 1000 100 10 <br /> 0 ,f qp�TPH IMM ALLOWABLE TPM LEVELS (PPM) <br /> .i IESEL 10,000 1000 100 <br /> FOOTNOTES: *"if documented soft and/or ground water contwination is present, do not camptete the leaching potential <br /> analysis. (i.e., site Is currently on UNIT 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 /> If precipitation is > 40 inches, score 0 points. <br /> Levels for BTXtE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOiMENOATION/CONCLUSION ,. <br /> I. Are BTX A E or TPN Concentrations > Allowable Levels Yes o <br /> 2. RecomtherhI Site Closure es if Yea, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SLUPERVISOR/SENIOR <br /> PITH STAFF RECOMMENDATION FOR CLOSURE ES EFERREO TO SITE MITIGATION FOR EVALUATION ES <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED ! / <br /> OF <br /> 'VALUATOR -z' +_" O/ /-7— <br /> G'16-aelt <br /> EN 23 80 (UGTWKSNT)\S/90 /� �� —7ia t~' rZ�.,nfo— <br />