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Ile - a-7 -- �5i <br /> SAN JOAOUIN-ANTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HNIA DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 13/0 <br /> AME OF FACILITY M440, U"e_� S u WEEPS CODE l e7_7 <br /> DORESSs nTANK ID # <br /> TANK SIZE I IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> *w <br /> Is permit current? leas o ermit # acility Status Code oc.Soil/GW Cont as 0 <br /> umber of Tanks at facility Nge of Tanks(if available) ype of Tank ISteel Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? as I IN01 if yes, give date(s) <br /> as a repair made to the tank system? es NQ No f yes, what was repaired? .C> <br /> ns repair done under inspection? es ere soil samples analyzed? as to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophico long-term leakage I loverfitI, nknown 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received Ifes IVINd epth to Ground Water Woof/Year verage Annual Precipitation Nz 4 10-25 <br /> On-Site Wells) IYes o umber & Type Irr am ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R rondition <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) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) t None Unknown --- oresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown ` resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one G one <br /> COLUMN TOTALS>>>TOTAL POINTS JD + + /_6 <br /> Sample Result: B T X OR•-E,,)G RANGE OF TOTAL POIN 9 pts or more 41 - 48 pts 4potential <br /> g D -l0� �ham^ <br /> �0-C) VJP B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM t 50 50 50 .3 .3 1. 1. <br /> 'ample Result: ASOLIN 1000 100 <br /> 1Q N N AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 1ESEL 10 000 1000 <br /> FOOTNOTES: ***if documented soil and/or ground water contamination is present, do not complete the leacanalysis. (i.e., site is currently on UGT Contamination List for soil or ground wa <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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Yes o If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />