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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1` UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE4AM <br /> E OF FACILITY 1�l OM1 �a�� SCrJc� e tI jl'� SWEEPS CODE. 1p�5 <br /> DRESS a a g 1 S. <br /> HWy qCjTANK-10 # <br /> ARK SIZE UEL TYPE •3Q-Ice 0 -0 t 10,000 tele l <br /> 1 0 <br /> II. GENERAL SITE HISTORY d'3 ]p,poo l�rltacW_-(ACL p S <br /> O'{ _ to Opo cLtCSeI <br /> ** <br /> Is permit current? es o ermit # - <br /> acility Status 6ode5� oc,Soit/GW Con es o <br /> F <br /> umber of Tanks at facility i G <br /> q— ge of Tanks(if available) V yl( ype of Tank teet rg! ngl <br /> III. TANK HISTORY rev,�d�/e.d �• i5 • g �� <br /> .'r <br /> Jas Tank tested? es o ailed precision test ? es o If •yes, give date(s) <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? E <br /> Jas repair done under inspection? es No ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of faiture/discharge atastrophic long-term leakage verfiltownk Cher: <br /> ,h <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORI FOR SITE DETAILS/COLLECT DATA FOR .LEACHINIG POTENTIAL ANALYSIS) <br /> -- <br /> oil Samples Received es o epth to Ground Water 70 of/Year ,^ ;� verage Annual Precipitation = 4 0-25 <br /> -Site WeLL(S) es o umber & Type Irr om ub <br /> S core S core S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 0 pts '; C pts C is <br /> 0 if 0 if 0 fp <br /> i. R condition R condition: R ondition <br /> Site Feature - Leaching Potential Analysis E "s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3>100 1 1-100 25-507 <br /> ractures in subsurface (appties to foothills or mountain areas) 'None r Unknown resent <br /> %verage Annual Precipitation (inches) KXXXXX ',<10 9 10-25 rxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None unknown Dresent <br /> If nique site features: Recharge area, coarse Boit, nearby wells. At least 4ore than } <br /> Xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS Ad. <br /> m le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B IT X E I� B T Ix. <br /> EMAXIMUM ALLOWABLE B-T-X_E LEVELS (PPM) i SO !Sa 50�� .3 .3 1 1. NA]3 <br /> ample Result: 100 10 SOLiNE 10011 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) ,r <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, da not comptete the leaching potential . <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth '1=5 ft:; do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. 1 <br /> 13 Levels for 8TX&E are not applicable at a TPH concentration of 10ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 0 ►�!MIa: S �� <br /> 1. Are BTX & E or TPH Concentrations > AlLowable Levets Yes o t►►CC''11tt�� c+e�'�-tyW~� � �1 <br /> o If Yes, Refer to Site Mitigation for Evaluation <br /> 2. Recommend Site Ctosure Fes <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR 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 <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 o, <br /> y <br />