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/4- <br /> SAN JOACUIN CAdL1C HEALTH SERVICES/ENVIRONMENTAL HEALT* ION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE / <br /> AME OF FACILITY ,�fc-DAFP £ v?, 14ZNZ_L SWEEPS CODE G(3,5 <br /> OGRESS �I �� Ar�CUi¢Y �� TANK ID 9: ' - c(7jc-1 v <br /> TANK SIZE 15Q! UEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> r <br /> -* <br /> iS permit current? es a ermit /f - acility Status Code oe.Soil/GW Cant es o <br /> tenber of Tanks at facility ge of Tanks(if available) ype of TankLeel Fbrgt rigl Dua! <br /> Ill. TANK HISTORY <br /> as rank tested? es o ailed precision test ? es o If yes, give dates) <br /> Jas a repair made to the tank system? es No f yes, what was.repaired? <br /> is repair done under inspection7 es o ere sail samples analyzed? es o I TXE :. PH-G I PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term teak age verfilt nknown ther: , <br /> I <br /> I <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECTI'DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es o epth to Ground WatereF/Year �d'� verage Annual Precipitation <br /> Site Wet!(s) es o tmber 8 Type Irr om vb I <br /> S core S Scare' S core = 1 <br /> istance to Vett(s) from Tank `L�l ft; f r ft C 0 pts C pts C pts <br /> O if O if 0 F <br /> R ondition R conditi6n R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met . E dis met E is met <br /> inimum Depth to groundwater from the Soi! Sample tfeet) .71---fC 6�:i_ ' X100 41 I=100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) a None q Unknown resent <br /> verage Annual Precipitation (inches) ii; <xxxxx -CIO 9 10-25 xxxxxx 26-40\2 <br /> f <br /> an-?wade conduits which increase vertic migration <br /> Ir <br /> f Leachate (i.e., septic systems ter Wei ponds) ' None Unknown 31resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than. <br /> xxxx None one one <br /> :i <br /> 'ell <br /> f <br /> COLUHN TOTALS»>TOTAL POINTS + h + .h <br /> amp(e Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more - 48 pts., 40 pts or less <br /> S. r <br /> MAXlML24 ALLOWABLE B-T-X-E LEVELS (PPM) 1: 5D 50 Jr0 .3 -3 1. 1., NA\3 <br /> ample Result: ASOLIN> 1000 100 L 10 <br /> AXIHUH ALLOWABLE TPH LEVELS (PPM) J <br /> ZLQ O TPH�� IESEL ,-, 10,000 1000 100 <br /> 0OTNOTES:: *--If documented soil and/or ground water contamination is present, a not comp the, leaching potential <br /> analysis. (i.e., site is currentty on UGT Contamination Listi 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 /> ti <br /> STAFF RECOMMENDATION/CONCLUSIONSv,�c'T� <br /> 1. Are 3TX &. E or TPH Concentrations > Allowable Levels Yes o ' �r �=V <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation k <br /> - E <br /> I. REVIEW EVALUATION - TO BE CCHPLETED BY A SUPERVISOR/,SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESIV 0 EFERREO TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED Z / ATE CLOSURE LETTER MAILED <br /> +AHE OF <br /> :VALUATOR <br /> - II <br /> EH 23 80 (UGTWKSHT)\5190 ' <br />