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SAN JOAOUIN MINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEArrM DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FAC ILITY �� WEEPS CODE �'S <br /> DDRESS .0}'�-3 ys.\„p,/1Cf ANK ID # ?J (�_ZO�S-D <br /> TANK SIZE $p FUEL TYPE h,n�, �cl.✓�{'( ttemoj <br /> II. GENERAL SITE HISTORY 62-5 '3 <br /> ♦e <br /> Is permit current? es iI0rmit # acility Status Codel,5( ec.Soil/GW C es Jo <br /> umber of Tanks at facility be of Tanks(if available) ype of Tank Leel Fbrgl rgl I Dual <br /> III. TANK HISTORY I CovIfxx_*t-_ <br /> as Tank tested? es I o ailed precision test ? IT as I o I If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection) es o ere soil samples analyzed? as I Jo I TXE PH-G ITPH-D b/EDO <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown1 10 ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samptes Received as o epth to Ground Water of/Year ;$s verage Annual Precipitation = 4 10-25 <br /> -Site Wells) as o I umber & Type I Irr I om I ub <br /> S, <br /> core S Score S 3core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditlon R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 45.S-39' >100 1.100 5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) ra None Unknown resent <br /> veroge 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 9 Unknown resent <br /> InigUe site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS �D 2 -4 1 + S 4 Z <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> FNo 5PPF4 <br /> S' I -E50FM B T E B T X E <br /> NDo btN'h MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> VLS•DO-ample Result: ASOLINE 1000 100 10 <br /> ll//� AXIMUM ALLOWABLE TPH LEVELS (PPM) � I i <br /> D TPH IESEL 1 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 TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION � � 1�y Dlch(orubenZG <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yeso ,ID PpM <br /> 2. Recommend Site Closure [es o If Yes, Refer to Site Mitigation for Evaluation PPM i�J, Il.-rktao'n 4 <br /> tv� +P <br /> �1 <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 JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br /> EH 29 60 <br />