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titi <br /> RONMENTAL IH LaH DIVISION <br /> SAN JOAQUIN COUNTY:PUBLIC HEALTH SERVICES/ENVI ATE <br /> UGST'WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I• LIEEPS CODE q$6 <br /> AME OF FACILIT'I $ �'Tb/`l IpG+�7'/dG- pHK 1D # S9 - i�rSsG 0 1 <br /> DRESS 637_ S. 1l POA4bZ> <br /> ANK SIZE Zioop UEL TYPE U�� <br /> AA <br /> II. GENERAL SITE HISTORY <br /> is permit current? es o ermit it <br /> acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility O ge of Tanks(if available) vae <br /> of lank teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es x o ailed precision test 7 es <br /> X o if yes, give date(s) <br /> as a repair made to the tank system? es + No f yes, what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage Verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECT ION REPORTI,FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> el gb verage Annual, Precipitation 'k= <br /> 4 0-25 <br /> oil Sa pLes Received es o epth to Ground water 30of/Year S ; <br /> -Site Wells) es o unbar 8 Type lrrOM ub S core <br /> 5 core S tore <br /> ftis <br /> C 0 pts C pts o "fP <br /> istance to WeLI(s) from Tank ft; ; ft 0 if 0 if <br /> R ondition Rcondition R ondition <br /> E is met E s met E s met <br /> Site Feature - Leaching Potential Analysis <br /> i <br /> inimum Depth to groundwater from the SoillSample (feet) <br /> ),100 1-I00 25-5011, <br /> resent <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown <br /> verage Arcual Precipitation (inches) xxxx <10 9 10-25 xxxzxx 2b-402 <br /> an-Made conduits which increase vertical migration None \ Unknown Dresent <br /> f leachate (i.e., septic systems, water wells, ponds) <br />€ At least 4ore than <br /> n-sque site features: Recharge area, coarse soil, nearby wells. xxxx None Ok one one <br /> COLUMN TOTALS»),TOTAL POINTS <br /> ample Result: [B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> p= _7o0'f`3�K7 <br /> 7' 'S�tlp ' gonuo B T X EB T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA 1. <br /> ASOLINE 1000 100 10 <br /> ample Result: <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> 3 app �P" TPH IESEL 10,000 1000 <br />' amination is present, do not complete the leaching potential <br /> FOOTNOTES: ***If documented soil and/or ground water cont <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 /> 13 Levels for BTXBE are not applicable at a TPH—concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENQATION/CONCLUSION L' r V 1�l �vf ��a/)� � P Sty' E Or'�+ <br />} 1. Are 8TX 8 E or TPH Concentrations > <br /> 2. Recommend Site Closure es o 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 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES K 0 <br /> ATE REFERRED / / GI ATE CLOSURE LETTER MAILEQ / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/ <br />