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SAN JOAQUINONTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H41H DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I JZ- Z.3 `t I <br /> AME OF FACILITY �N 304 U t�, 1 biro w1 anapkriqISWEEPS CODE �ZL.I <br /> DDRESS 23G, Wes SCO5 S{-�Ck-�Z� ITANK ID # <br /> TANK SIZE ' UEL TYPE Y �jV,4 <br /> II. GENERAL SITE HISTORY <br /> Is permit current7 os iI, ermit # acility Status Code Cj D oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) Yg [Type of Tank teel rgl I isng <br /> l �D a <br /> Ill. TANK HISTORY 14a-lr <br /> = k. .g6 <br /> as Tank tested7 es o ailed precision test ? as o If yes, give date(s) / <br /> as a repair made to the tank system? as No 1 11f yes, what was repaired? <br /> ns repair done under inspection? es I No ere soil samples analyzed? es )o TXE -G H-D b/EDD <br /> Type of failure/discharge atastrophic Long-term leakage I <br /> verf ill nknown 1 10 <br /> ther: <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 Water �315 cf/Year ; 1 verage Annual Precipitation = 4 10-25 <br /> -Site Wells) 1Y <br /> as o umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R onditi on 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)35-16.5=a45 >100 1-100 ® 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 19 Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX 00 9 10.25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration - <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. q At least ore than <br /> xxxxx None f one one <br /> COLUMN TOTALS>>>TOTAL POINTS b + 3 + O <br /> ample Result: (D T X OR E RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> BTND Py� <br /> G T X E B T X E <br /> N MAXIMUM ALLOWABLE B.T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> tl 1 A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> V e TPS 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppn (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION / <br /> 1. Are DTX 8 E or TPH Concentrations > All, Levels Yes oI 7T <br /> �� <br /> 2. Recommend Site Closure es ' / 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 L EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF c <br /> VALUATOR (� <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />