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SAN JOAOUIN%NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL AN DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 . Z3 •('(' <br /> AME OF FACILITY �� L1If1 C_-J.yy_"UE-A yL✓.L-, rtq WEEPS CODE <br /> DDRESS _ J! W�c SGS bJs ") UGkJl 1'\ ANK ID # <br /> TANK SI2E rj1000 y1 UEL TYPE diesel 7 <br /> 11, GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acil ity Status Code 6C) oc.Soil/GW Cont as o <br /> umber of Tanks at facility ge of Tanks(if available) 1 ! V5 IType of Tank tee rgl I ngl I_,,duet <br /> 111. TANK HISTORY ln.$W I <br /> v <br /> as Tank tested? esI IK ailed precision test ? as o I if yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired7 <br /> ns repair done under inspection? es o ere soil samples analyzed? es o TXE -G H-D b/EDG <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 /> oil Samples Received es o ep[h to Ground Nater 35 et/Year S' n verage Annual Precipitation A= 4 10.25 <br /> -Site Wells) es o I 'ober 8 Type Irr I om I ub <br /> S core S Score S Score <br /> istance to Wetl(s) from Tank ft; ft; ft C 0 pts C pts C pts _ <br /> ' '0 if 0 if 0 if <br /> R condition R condi ti on R ordition <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) 35-13. I. >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10.25 xxxxxx 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 /> lnique site features: Recharge area, coarse soil, nearby wells. At toast 4ore than <br /> xxxx None 2� one one <br /> COLUMN TOTALS»>TOTAL POINTS O 3�O + C)) 36 <br /> am le Result: (B T XORp�E RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> T X E B IT X E <br /> x- �p V✓PPb� MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Result: <br /> O M � A%IMUM ALLOWABLE TPH LEVELS (PPM) ASOLINE 1000 100 10 <br /> TPH_ <br /> IESEL 1 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or grand 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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION *6 <br /> 1. <br /> Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> I 7T Z. Recomaend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VT1. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR O Y <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />