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SAN JOAQUIN COUNTY JLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH C ; ION <br /> I. I . UGST WORKSHEET FOR SITE CLOSURE EVALUATION _ ATE 3 _ A _ 9 <br /> AME OF FACILITY i / WEEPS CODE 1 ZZS�! <br /> DDRESS 64 � Z� p �IANK1�0p <br /> TANK SIZE vA n . ;r, , . UEL TYPE �( \CFN/Y<M'JC-C. 77 l`7 of "CI TTUJL- �wc-/l.Ll�r) �C <br /> 11 . GENERAL SITE HISTORY <br /> Is permit current7 as :to <br /> ermit N - acility Status Code oc . Soil /GW Cont es Fm <br /> umber of Tanks at facility Be of Tanks ( if available ) ype of Tank Leet Fbrgl ngl Dual <br /> III , TANK HISTORY <br /> as Tank tested? as 01 IF <br /> ailed precision test 7 as o If yes , give date ( s ) <br /> as a repair made to the tank system? es No f yes , what was repaired? P <br /> as repair done under inspection? e!*Tqo ere soil samplesanot yzed? es o TXE PH- G PH -0 b/EDB <br /> ype of failure/discharge atastrophic long - term leakageve 1 L nknown ther : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received es I o epth to Ground Water Ah of/Year verage Annual Precipitation = 4 0- 25 <br /> r Site Welt ( s ) as o lumber 8 Type Irr an ub <br /> S Score S Score S Score <br /> ? stance 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 condition R condit1on R ondition <br /> V . Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ? nim Depth to groundwater from the Soil Sample ( feet ) > 100 51 . 100 5 25 . 50\ 1 <br /> ractures in subsurface (applies to foothills or mountain areas ) None Unknown resent <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 9 Unknown >resent <br /> pique site features : Recharge area, coarse soil , nearby wells . At least 4ore than <br /> xxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS 0 + 2 + f Q 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 /> B T X E B TX <br /> E <br /> MAXIMUM ALLOWABLE B - T - X- E LEVELS ( PPM ) 1 50 50 5 . 3 . 3 1 . 1 . NA\3 <br /> ample Result : ASOLINE1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS ( PPM ) <br /> TPH IESEL 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 BTXBE are not applicable at a TPN concentration of 10 ppm ( gasoline ) or 100 ppm ( diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION <br /> I � � �n?� <br /> 1 . Are BTX $ E or TPH Concentrations > Allowable Levels Yes o t& w"d Lam" " �/k 'Jitt I I) <br /> I2 , Recommend Site Closure es No If Yes , Refer to Site Mitigation for Evaluation <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 /> 1AME OF <br /> : VALUATOR <br /> CH 23 80 ( UGTWKSIIT ) \5/90 <br />