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SAN JOACUIN%TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�OiVISION 3 _a7- F 7 <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> ANE OF FACILITY � ECORD ID a3 ,�p 9O <br /> %DDRESS 7O S ' ✓16 CffqQANK ID # <br /> QQ <br /> ANK SIZE a O DELI TYPE �CCCY. <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code , oc.Soi L/GW Cont as o <br /> umber of Tanks at facility �ge of Tank(if available) . 56 �ype of Tank teal IlFbrgL ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? as o ailed precision test ? i Yes orx if yes, give date(s) <br /> as a repair made to the tank system? es No Itf yes, what was repaired7 <br /> as repair done under inspection? es oere soil saples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atasrrophic long-term Leakage verfill noun they: <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 Water44 of/Year 1?& ; verage Annual Precipitation = 4 U-25 <br /> -Site WeLL(s) es o umber & Type Irr om ub <br /> S core S core S core <br /> istance to WeIL(s) from Tank ft; —ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 f <br /> R audition R ordition R ondition <br /> V. Site Feature - Leaching Potential Analysis E "s met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) ;C)— >100 1.100 I_-J 25-50\1 <br /> Fractures in subsurface (applies to foothills or m0untain areas) I D None Unknown resent <br /> verage Annual Precipitation (inches) axxxx <10 9 10-25 KXXX=X 26-40L2 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wet Is, ponds) None Unknown resent <br /> nicue site features: Recharge area, coarse soil, or wells. At Least ore than <br /> cmuncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present) xxxx None 17 one one <br /> 1 /3 - .cb12- 7-z ,5(D F- . 1`!a X = . 3 ?D � //� <br /> COLUMN TOTALS>>>TOTAL POINTSWN p33D 10 ' 1� - _.5 / <br /> ample Result: (B T X OR E) RANGE OF TOTAL PO1 9 pts or more I 41 - 48 pts 40 pts or less <br /> 1 1 /U� lylL3 ,ola 1 �y <br /> 8 T X E B T X E <br /> �a'Y X- ,D L I MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: SOLINE 1000 100 10 <br /> K I S -5 (pTY 06M �AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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., sit= is currently on UGT Contamination List for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. if depth c=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (d <br /> i <br /> e <br /> sel). J <br /> VI. STAFF RECOMMENDATION/CONCLUSION �1�S'p�upV� ��.:�Ca lvI Pt <br /> 1. Are BTX & E or TPH Concentrations + Allowable Levels Yes o 7 a $3$O NO2i�s<if5 <br /> M713� - 0 <br /> 2. Recommend Site CLosu Refer,No It Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE CQePLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED " /-Z /�''I ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />