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SAN JOAOUIN NTY PUBLIC HEALTH SERVICES/i:NVIRONMENTAL H H DIVISION <br /> 1. UGST WORKSHEETS FOR SITE -CLOSURE EVALUATION ATE <br /> AME OF FACILITYSWEEPS CODE ZCI`tA3 <br /> DDRESS L}2�C VTANK ID #' I <br /> TANK 51ZE1poO Q- UEl TYPE <br /> Ik Il. GENERAL SITE HISTORY <br /> Is permit current? es o vfr,it # t acitity Status Code 011 oc.soil/GW Cont es o <br /> umber of Tanks at facility be of Tanks(ff avaitable) [/Ylk IType of Tank 13teet. gt ngt ual <br /> Ill, TANK HISTORY <br /> as Tank tested? es o sited precision test ?, es a If yes, give dates) / <br /> as a repair made to the tank system? Yes No fiyes, 'what was repaired7 <br /> ns repair done under inspection? es� o ere.soil samples analyzed? es a TXE G H-D b/EDB <br /> ype of faiture/discharge atastrophic to, <br /> Leakage verfitl nknownther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water ?J of/Year ♦<� verage Annual Precipitation N= 4 10-25 <br /> )n-Site Wett(s tto <br /> umber & Type Irr am x ub <br /> S Score S Score 'S Score <br /> istance to Welts) from Tank ft; ft; 'VVI t C lo pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R andition <br /> V. Site Feature - Leaching Potential Analysis ' E is met E is met E .'s met <br /> 1 inimum Depth to groundwater from the Soit'Sample (feetj 1psitln Q Cjs >100 5 1-100 5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) J ID None Unknown resent <br /> i <br /> verage Annual Precipitation (inches) !t Kxxxxx <10 9 10-25 xxxxxx, 25-40\2 <br /> nn-Made conduits which increase vertical migration r <br /> f teachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> mi g , , <br /> gtie site features: Recharge area coarse Boit nearby wells: _ Q At .least : ore than <br /> t xxxxx None I one one <br /> COLUMN TOTALS»>TDTAL POINTS .., ID + .k tJ + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POLNTS 9 pts or more. 41 48 pts GO pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E. LEVELS (PPM) 1 50 SQ 50 .3* .3 1. 1. NA\3 <br /> 9D . 1 10 .m' 1� -. 1, . J <br /> 'ample Result: glaotfb ASOLINE 1000 100 10 <br /> GL AXIMUM ALLOWABLE TPH LEVELS:_.(PPM) <br /> CJRMTPH IESEL. 10,000 1000 100 <br /> QOTNOTES: ***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 /> VI- STAFF RECOMMENDATION/CONCLUSION <br /> t. Are BTX & E or TPH Concentrations > Allowable Levels Yes I INO /m j::>` 1 <br /> 2, Recommend Closurees o If Yes, Refer to Site Mitigation for Evaluation <br /> vll. REVIEW £VALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR acce- <br /> 1eV'e.,S <br /> CNCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES O EFERRED TO SITE MITIGATION FOR EVALUATION rs D <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />