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SAN JOAOUIN CCUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HATH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY u0G_�(_ Q/f(T� Go• 2N[. WEEPS CODE �(�b <br /> DRESS ' p'�jj L - �F�fi(•(0(J'r ANK 1D # <br /> TANK SIZE 1 UUO UEL TYPE I VII, <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit # - acility Status Code L�Zj ac.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank LLel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es �( o ailed precision test 7 es x o If yes, give date(s) 3 //Z &4 ; <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es 40 ere soil samples analyzed) es o TXE 1 PH•G I PH-D b/EDB <br /> Type of failure/discharge atastrophic long-tenn leakage I—Tverf ill nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es I X o I epth to Ground Water "t, of/Year - verage Annual Precipitation = 4 0-25 <br /> On-Site Wells) es I o umber 8 Type I Irr m I ub <br /> S core S Score S core <br /> istance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if O if 0 f <br /> R ond'Ition R conditiort R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met Es met <br /> inimun Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011, <br /> Fractures in subsurface (applies to foothills or mountain areas) None \ unknown resent <br /> Average Annual Precipitation (inches) KXXXXX <10 9 10.25 Kmxmx 26.40E <br /> %an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> %xxx Noner, one one <br /> COLUMN TOTALS>>>TOTAL POINTS • 2�6 tI - ' /- <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> .Sq <br /> iJ00pp" B 1 T % E B T % E <br /> X- / JO`�h MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> �,ok 000 r?�ak TPH 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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> J2 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION E V4�Vc 0 7 <br /> 1. Are 8T% 8 E or TPN Concentrations > Allowable Levels Yes x o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / �� / ;� ATE CLOSURE LETTER MAILED <br /> AME OF - <br /> "VALUATOR j%1is,•- `� <br /> EN 23 80 (1.03TWKSHT)aS/40 <br />