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SAN JOAQUINoWITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE VISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ptcr <br /> AME OF FACILITY I G®�` Q u ECORD ID b <br /> ADDRESS ZZ lj GC>G / O®,T ANK ID # {Q�Z.9 <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank teel Fbrgl ngl I Dual <br /> ill. TANK HISTORY <br /> as Tank tested7 es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Pas repair done under inspection? es o ere soil samples analyzed? lies o TXE I PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic tong-term leakage verfill nown I lother- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received �es I IN01 epth to Ground Water of/Year ��j fi94verage Amual Precipitation k= 4 0-25 <br /> n-Site Wetl(S) es I o I umber & Type I Irrom ub <br /> S Score S I Score S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) ^ 25 )100 I 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 01Unknown resent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-4012 <br /> Ian-Made conduits which increase vertical migration q <br /> Df leachate (i.e., septic systems, water wells, ponds) None I Unknown resent <br /> �nique site features: Recharge area, coarse soil, or welts. O� At least ore than <br /> (muncipat=>2000 ft; domestic=>500 ft; irr/agricultural=present] None / one one <br /> COLUMN TOTALS>>>TOTAL POINTS -56 J_ e_{ <br /> II Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 t 40 pits or less <br /> B I T jXTEB T X E <br /> A).0• ; MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 5050 .3 .3 1. 1. NAL <br /> am�y�l Re ult: SOLINE 1000 100 10 <br /> n F-�-- f'OAS" AXIMUM ALLOWABLE TPH LEVELS (PPM) I t— <br /> M4 1-?d TPH s Ar IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth —5 ft., do not use table. <br /> 122 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 ��SEf T.roE*�G6i ®eI 6wOt ,c" C = d.4. - .$yw <br /> 4 rper+ <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o I If Yes, Refer to Site Mitigation for Evaluation or. <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES I 0 EFERRED TO SITE MITIGATION FOR EVALUATION E5 0 <br /> Ai-c REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />