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SAN JOAQUIN I&CINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION q <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �. Z�• { Z <br /> AME OF FACILITY BlU"Q. �L.tq tG 4'y��JG-kS WEEPS CODE �CJ. <br /> DORE SS wTf TANK 1D p <br /> ANK SIZE I 1,UEL TYPE 39- 1$q--0- 0/ GOOD 50-4 url(,,cxL (!t <br /> II. GENERAL SITE HISTORY 39- (54-D-02— f000 to dlewi <br /> Is permit current? as o ermit # acility Status Code 15 ID oc.Soll/GW C os o <br /> +umber of Tanks at facilityl 2 ge of Tanks(if available) Lnv-- IT <br /> ype of Tank tee[ rgl <br /> 111. TANK HISTORY <br /> as Tank tested? es o ted precision test ? as I IHOI If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired7 <br /> ms repair done under inspection? as o ere soil samples analyzedt as o T%E -G PH-D b/EDO <br /> Type of failure/discharge atastrophic long-term Leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Fall Samples Received es o epth to Ground Water .q. of/Year `f verage Annual Precipitation 4 10-25 <br /> -Site Well(s) as o I umber 8 Type Irr om ub <br /> S Score Score S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 1f 0 if <br /> R ondition R ondition R ondition <br /> v. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)46-15, >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 1p None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26.40\2 <br /> an-Made conduitswhich a vertical migration <br /> ( leachate (i.e., eptic stems, ter wells, ponds) None Unknown 5 resent <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: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> xr dD Q . 2 Fr1 <br /> PP G T X E B T X. E <br /> MAXIMUM ALLOWABLE O-T-X-E LEVELS (PPM) 1 5 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: —r"v ASOLINE 1000 100 10 <br /> t,t�� I D AX IMUM ALLOWABLE TPH LEVELS (PP ) <br /> "W TPH •T'P{{� hp} gt'W ZK� 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 STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION OD Pb LP-44P -tomo � <br /> 1. Are BTX 8 E or TPH Concentrations > Alloua le Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation Y'Qq u1H'QS r^a7 O1J61�t�" <br /> . <br /> VII. REVIEW EVALUATION - TO BE CgfPLETEO BY A SUPERVISOR/SENIOR -haslh k15W <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 Lrc> / — / 7 i-1 <br /> .VALUATOR `7 f--- <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />