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SAN JOACUIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL VISION <br /> 1. UGST WORKSHEET FOR SITE nCLOSURE EVALUATION A I E <br /> nME OF FACILITY I 6y (L LDLr1L' %�;Cr ��Gtile- SEEPS CODE <br /> OORESS I -�U�'I (/f//U f ✓ J ANK IO <br /> rnNz SIZE %o' /OCG UEL TYPE <br /> It. GENERAL SITE HISTORY <br /> is permit current7 es o ermit k - acility Status Code oc.Scil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT <br /> ype of TanLL eel Fbrgl ngL Dual <br /> III. TANK HISTORY <br /> 'is Tank tested7 es I INO <br /> ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> :as repair done under inspection7 esof ere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic (long-term leakage verfill nknown I locher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COL;ECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Foil Samples Received I es o epth to Ground '.tater of/Year -? verage Annual Precipitation = 4 0-25 <br /> Dn-Site Welt(s) 1Y <br /> es o umber & Type Irr I ub <br /> S core S Score S Score <br /> )!stance to Well(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ini;Txm Depth to groundwater from the Soil Sample (feet) _ ` >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) one a Unknown present <br /> verage Annual Precipitati3n (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Rade conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown t resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At leastore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B 1 T X E B T X E <br /> MAXIHLk1 ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXINJM ALLOWABLE TPH LEVELS (PPM) <br /> 7Ut7�,�wj TPH 'C IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> /1. STAFF RECC4,VENDATION/CONCLUSION <br /> 1. Are BTX 8• E or TPH Concentrations > Allowable Levels Yes o /�( <br /> 12. Recomnerd Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> .'II. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -CNCJR WITH STAFF RECCFiMENDATION FOR CLOSURE IES 0 I EFERRED TO SITE MITIGATION FOR EVALUATICN ES 11 0 <br /> DATE REFERRED _,/ / `l ATE CLOSURE LETTER MAILED f / <br /> :n ME OF LV <br /> y� <br /> EH 23 30 (UGTWKSHT)\5/90 <br />