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SAN JOAQUICOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H�N DIVISION ATE .—p Y3 <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> Irl�T I <br /> AME Of FACILITY p M�. �'1 't ( 1(S I L, WEEPS CODE 0_9 <br /> DDRESS X049 S, V\vSoh VV I. ANK ID d <br /> TANK SIZE CO Ub UEL TYPE I ,Yl CO e, <br /> 11. GENERAL SITE HISTORY ** <br /> F <br /> it current? es oermit A acility Status Code oc.Soil/GW Cont es to <br /> of Tanks at facility ge of Tanks(if available) ype of Tank Leel FbrgL net Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o Lf yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under Inspectiont es o are soil samples analyzed? as 1 10 1 TXE IrPH-G I PH-D b/EDB <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 I'� o I epth to Ground Water (, of/Year ) ; 6.6 verage Annual Precipitation = 4 10-25 <br /> in-site Wetl(s) es I o 11 umber & Type I Irr om I ub <br /> S Score S Score s Score <br /> {stance to Wells) from Tank it; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R zondi tion <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),4 0- -:3j >100 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <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) R3 None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one a/,— one <br /> COLUMN TOTALS>>>TOTAL POINTS ;0 + I B + J '13 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> D <br /> .y 1 B T X E <br /> N ¢ 1 ,o d ; 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 /> N P CL's ` f.� TPN AXIMUM ALLOWABLE TPN LEVELS (PPM) IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do n tete 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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es 17Fo I If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION . TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 10 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 00 (UGTWKSHT)\5/90 <br /> Ex 29 80 O(J <br />