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SAN JOAQUIN ItO NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEATH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE .3 <br /> AME OF FACILITY EEPS CODE 2 E <br /> DDRESS �l.I 3 F{/Q,Yv) _ ANK ID p <br /> TANK SIZE UEL TYPE I re fe v-%� <br /> II. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? as o ermit k acility Status Code oc.Soii/GW Cont es to <br /> umber of Tanks at facility ` he of Tanks(if available) LG [Type of Tank teel I Fbrgl ngl Dual <br /> Ill. TANK HISTORY re"Ioue to•25•gb �,Q,F.�_ <br /> WI'SwlLec( 1430 <br /> as Tank tested? es o tied precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Ifas o I f yes, what was repaired? <br /> n5 repair done under inspection? es o ere soil Samples analyzed? es Io TXE PN-G PH-D b/EDD <br /> Type of failure/discharge atastrophic long-term leakage I verfill I .known er: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 10.25 <br /> -Site Welt(s) as o umber 8 Type Irr on ub <br /> S core S Score 5 Score <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R conditior, R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inirtAm Depth to groundwater from the Soil Sample (feet) >100 1-100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <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, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <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 E B T X. E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ���..17�71�TPH 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 /> \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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION f I-p-qc K r-e_V ( j--Q <br /> ^ t <br /> i, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o �--16;) <br /> -T� 10-0.5 <br /> 2. Recommend Site Closure ITes o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE C011PLETED 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 <br /> EH 23 BO (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />