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SAN JOAQU%WXUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL NLTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY t4oI+ Br d S SWEEPS CODE <br /> DRESS 1541 C kc,(-+e-,r <j�6 y� TANK ID # <br /> ANK SIZE 7500 lei iFUEL TYPE D IQ Se I S�o o b IL <br /> k <br /> II. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility Status Code oc.Soit/GW Cont es o <br /> umber of Tanks at facility 57 15;) u ge of Tanks(if available) ype of Tank tee? )(Fbrgl ngt NDuat <br /> III. TANK HISTORY .2I <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) ` / <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> Jas repair done under inspection? es No ere soil samples analyzed? es o TXE PH-G PH-D , b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfitl nknown ther: <br /> IV. REMOVAL HISTORY (ATT CH IySPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) k,..,jt,, d ufa7 W <br /> m <br /> Soil Samples Received es ✓IN01 epth to Ground Water of/Year t-?- verage Annual Precipitation = 4 0 25 <br /> n-Site Welts) es o umber & Type Irr om ub <br /> S Score S Score S core <br /> istance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> i. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) Q None Unknown DIresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-4012 <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. q At least 4ore than <br /> xxxxx None / one one <br /> COLUMN TOTALS»>TOTAL POINTS I U + -7 + 3 -7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> N-6I U ��� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM)F15 <br /> 50 50 .3 .3 1. 1. NA13 <br /> ►.J <br /> Sample <br /> Result: <br /> esOt: J PC, ASOLINE 1000 100 10 <br /> PP AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH b IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH 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 f 14 c `—S n 6+ <br /> �C!/VL�C1 ' <br /> 2. Recommend Site Closure es o V ta <br /> !f Yes, Refer to Site Mitigation for Evaluation ac.-�I �- <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES1 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />