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SAN JOAQUI ONTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Ha DIVISION <br /> i UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 r <br /> AME OF FACILITYc' ECORD ID h 11) T1 , J <br /> DDRESS W ANK ID # 131 - 57 <br /> ' <br /> TANK SIZE >✓ ') i ' UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> +,r <br /> Is permit current? es ✓ o ermit # - acility Status Code Soil/GW Cont es e <br /> umber of Tanks at facility ] ge of Tank(if available) We of Tank keel Fbrgl I IS <br /> ngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es IFailed precision test 7 es o if yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es a TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> cit Samples Received es o epth to Ground Water I of/Year } verage Annual Precipitationr40-25n-Site Wells) es o umber & Type IrrS core S core S istance to Wells) from Tank ft; ft; ft C 0 pts C pts C 0 if 0 if 0 <br /> R condition R condition 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) >100 1-100 i 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) l/ G} None Unknown resent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) �,; None Unknown 3resent <br /> nique site features: Recharge area, coarse soil, or weds. At least 4ore than <br /> [Muncipat=>2000 ft; domestic=?500 ft; irr/agricultural=present) xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + Ln %`1 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 _pts-or te <br /> —r1ti ' ' 1 1,01) B I 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 /> ample Result: ASOLINE 1000 100 10 <br /> AXiMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH - D 100'10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the le hirx) potenti <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 /> If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not appticabte at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> i. Are BTX & E or TPH Concentrations > Allowable Levels Yes o /C `ilt � J <br /> of <br /> 2. Recommend Site Closure es a If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> i <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES ✓ 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES / O <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />