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I <br /> ., • �. A - <br /> ' Ld <br /> SAN JOAQUIN COUNTY PUBLIC HHALTH SERVICES/ENVIRONMENTAL NEALTN DIVISION <br /> I. UG5T WOkKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY M 4217 EPS 'CODE <br /> DRESS STS( b TANK 10 N �� D <br /> TANK SIZE 0 1) UEL TYPE <br /> It. GENERAL SITE HISTORY <br /> Is permit current? es o ermit 1 - ecility Status Code .�. oc.SoIIJGlf Cant es o j <br /> umber of Tanks at facility Be of Tanks(If available): l q r7 type of Tank toel Fbrpl ngi, I Dual i <br /> I <br /> 111. TANK HISIORY <br /> as Tank tested? es h o ailed precision twat 7 ea a If yea; give date(s) ' <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> Jas repair done under inspection? as a ere salt samples analysed? es o TXE PN-G PH-D b/EDB <br /> i <br /> ype of failure/discharge atastrophictong-terra leakage verfill mown theri <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,I <br /> oil Samples Received es o epth to Groundeater D of/Year �� ;�21 verage Annual Precipitation 4 0-25 <br /> -Site wells) es a umber L Type 11 rr ars <br /> S core S Core S core <br /> istance to Yells) from Tank ft; ft; ft C 10 pts" C 91 pts C pts <br /> 0 it 0 if O f <br /> R ondition R condit(on R olWItIon <br /> 1. Site Feature - Leaching Potential Analysis E is net E is met E is met <br /> i <br /> inimum Depth to groundwater from the Solt Sample (feet) 3.100 1-100 25-50.4,1 <br /> Fractures in subsurface (applies to foothilts or mountain areas) None Unknown resent <br /> verage Annual. Precipitation (inches) xxxx 00 9 10-25 xxxxxx 26-40 2 <br /> nn-Made conduits which increase vertical migration. <br /> f leachate (i.e., septic systems. water wells, ponds) None Unknown resent' *19 <br /> ique site features: Recharge area, coarse soil, nearby wells. At Least 4are than I <br /> xxxx None one one <br /> COLUMN TOTALS TOTAL POINTS I ;7 J{ <br /> tirple Result: (B T x OR E) RANGE OF TOTAL POINTS 9 pts.or more dam- 8 pt 40 pts or less <br /> B T f( E T x <br /> MAXIMUM ALLOWABLE D-T-X-E LEVELS (PPM) 1 50 50 SO ��l.3 1. NAL <br /> ample 'Result: SOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1 PN IESEL 10,000 1000 100 <br /> r- 9Z2- <br /> OOINOTES: """If documented soil and/or ground water contamination is present, do a the leaching potential <br /> analysis. (i.e.. site Is currently on UGT Contamination List for soil or ground water.) <br /> 11 If depth is > 5 ft. and < 25 ft., scare 0 points, It depth <=5 ft., da rot use table. <br /> 1?, If precipitation is > 40 inches, scare 0 points. <br /> L Levels for BTXLE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX L E or TPH Concentrations > Allowable Levets Yes o <br /> 2. Recommend Site Closure es. o 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 I 0 EFERRED T8 SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF 1 <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/9 <br />