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SAN JOAQUIN LOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEANH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY -r\k�5 EEPS CODE 2 p R <br /> DDRESS ia9hU__E_L1TFPE <br /> �Z�_ rANK ID # 20 �'S-o( <br /> ANK SIZE 'P <br /> 11. GENERAL SITE HISTORY >•}. ( O ** <br /> Is permit current? es o ermit # acility Status Code 5e oc.Soil/GW Con es 10 <br /> umber of Tanks at facility he of Tanks(if available) IType of Tank IS Leel Fbrgl n9l Dual <br /> 111. TANK HISTORY If%6f*L 14}0 V164`L-'� <br /> riRADv .25.8(. <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired7 <br /> ns repair done under inspection? as 40 ere soil samples analyzed? es Jo I TXE PH-G I IF <br /> PH-D b/EDD <br /> typo of failure/discharge atastrophic long-teen leakage verfill mknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> mil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> )n-Site Well(s) as o 11umber 8 Type irr om ub <br /> 5 Score S Score S core <br /> istance to Wells) from Tank ft; _ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimun 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) 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, ponds) None Unknown Dresent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ample Result: (B T X OR E) p- RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 6 - mo wrim` A.2�•0 <br /> E - uo cope— `"I 8 B T % E <br /> T-_IJD Soapw MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> 100tWm'I TPHJ.o 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 LOT 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION1,1,1 -rb <br /> ,ckroG f'Yw- 60pp— <br /> c <br /> 1• Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o h[4)) .a v-00 VLCAS <br /> ( 2 Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <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 ES 10 <br /> )ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />