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SAN JOAQUIN *Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY (`_ J t 3crD WEEPS CODE <br /> ADDRESS ANK IDS y# _' <br /> TANK SIZE] UEL TYPE I b Z g�-A <br /> 11. GENERAL SITE HISTORY UST Z ®t>Z(A� <br /> Is permit current? eso ermit # acitity Status C oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT ype of Tank Leel Fbrgt ngl Dual <br /> ill. TANK HISTORY <br /> as Tank teste4? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system?IYes No f yes, what was repaired? <br /> ns repair done under inspection? es I No dere soit samples analyzed? 1Yes I 10 I XE PH-G PH-D b/EDB <br /> ype of faiture/discharge atastrophic tong-term leakage I verfitl I nknown them <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Gro Water of/Year Q vera a Annual Precipitation = 4 10-25 <br /> p ® <1971 �. 9 P <br /> Site Weti(s umber & Type irr om ub <br /> S Score S Score S Score <br /> istance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) O >100 1-100 sJ' 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown ,cJ� 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, pond,) , t® None Unknown resent <br /> Inlque site features., Recharge area, coarse soil, nearby welts. At least 4ore than <br /> xxxxx None 9 one 2 one <br /> COLUMN TOTALS»)TOTAL POINTS '1O + t + /o <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 LE B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 SO 50 .3 .3 1. 171 NA\3 <br /> Sample Result: GASOLINE, 1000 100 10 <br /> q \cam AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> ice-' 1 > TPN IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented snit 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> o if Yes, Refer to Site Mitigation for Evaluation <br /> 2. Recommend Site Closure Fejs <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 YES , 0 <br /> ATE REFERRED ! / ATE CLOSURE LETTER MA <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />