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SAN JOAQUUIN'MNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HtWld DIVISION Q <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY Qoll "CLLS 9,r) EEPS CODE 115(1 <br /> OGRESS 14-24' SOutv% LLVV_0[n :5jnC'V_tDV1 ITANK 10 # <br /> TANK SIZE j'000 SQ UEL TYPE G4S <br /> It. GENERAL SITE HISTORY ** <br /> Is permit current? es o ermit # aciLity Status Code Ej2 oc.Soil/GW Cont es Jo <br /> umber of Tanks at facility ge of Tanks(if available) U�l(L ype of Tank teee brgl ngl Dual <br /> I I 1. TANK HISTORY Y�mo✓ .ZZ• <br /> as Tank tested? es o ailed precision test ? es 0 If yes, give date s) / <br /> as a repair made to the tank system? Yes No I Vff yes, what was repaired7 <br /> Jas repair done under inspection? es 0 ere soil samples analyzed? 1Yes Jo TXE H-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term Leakage verfill nknown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as 140 epth to Ground Water 35 of/Year verage Amual Precipitation = 4 10-25 <br /> Dn-Site Wetl(s) es I o umber & Type Irr am ub <br /> S Score S Score S Score <br /> istance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feeQ 36,E:a7.5 >100 1-100 E5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) ID None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Axxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None q Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. G At least ore than <br /> xxxx None l one one <br /> COLUMN TOTALS>>>TOTAL POINTS D + Z + J L4 2- <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> S-90 4P .I R*-N <br /> �- 3.0 h,t 6 T X E B JT X E <br /> PP MAXIMUM ALLOWABLE B-T-X-E LEVELS (7PPM 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> PP r-1 TPH IIESEL. 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 at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION ur-kif- Pr m b �. <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes Jo �h ��CCft011,,�ttM'`-S <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation -FOL4n Z CDV-jALtL6n- P1' <br /> V1I. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR 0_on-fam(V14'h4n noW <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I IND <br /> EFERRED TO SITE MITIGATION FOR EVALUATION YES r0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />