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SAN JOACU nt COUNTY PUBLIC HEALTH SFR`/ICES/E4VIRONME4TAL nndALTH OIVISICN <br /> I UGST 'JORKSHE=T FOR SITE CLOSURE :VALUATION 1DATEI <br /> NAME OF FACILITY SWEEPS COaE <br /> AODRESS I i a lti� ' LI.,C✓f � S'iQ Jl /LIYL i I TANK ID :*i <br /> 1 TANK SIZE I_3(G`O&C, FUEL YPE '` 4 I t�_P11 uo'� � —S+q <br /> !I. GENERAL SITE HISTORY <br /> i �I 1 .. �4 IFacili Status Codec i0oc_Soil/G'.1 Can Yes IN, <br /> is permit current. Yes INC! IP_rmir i tY <br /> ;Number of Tanks at faciti+ 1Age of Tanks(if available)1 (Type of TankESteel[ (Fbrgll 1Sngl) Dual[ <br /> i11. TANK HISTORY <br /> Inas Tank tested? Yes iNol 1Faited precision test ?1Yes[ No If yes, give date(s)I <br /> !Was a repair ,made to the tank system?lyesl Vol Iff yes, what was repaired?( <br /> Was reaair done under inspection?1Yesj INoI (Were soil samples analyzed?lYesj INaI BTXEI [TPN-G! [TPH-OI [Pb/Ei)8� <br /> !Type of failure/discharge IcarastrophicI ltong-term leakage[ (over^itll [unknown! !other: <br /> EV. REMOVAL HISTORY (ATTACH INSPEi:7ICN REPORT FOR SATE DETAILS/COLLECT DATA FOR LEACHING POTENTiAI ANALYSIS) <br /> {Soil Samples ReceivedlYes {Mai [Depth to Ground 'darer} IRef/Yearl Average Annual PrecioitationjA=+14 110-ZS <br /> !On-Site WetlCs)[Yes1 [No 1Numoer Type [lrrl (Dam! [Pub{ <br /> S (Score S (Scare S Scare <br /> !Distance :v Wells) from rankft; -t C 10 pts C 9 pts C 5 pts <br /> 0 Iif 0 i. O if <br /> Rcondition R =ndition R condition <br /> V. Site Feature - Leaching Potential .analysis c �is .net _ its :met = Ps met � <br /> 'Minimum Depth to groundwater -ram the Soil Sample (feet) a_j ! { >f00 I j5i-1001 <br /> `5 16_50\i i <br /> IFrac:ures in subsurface (applies to -aothitls or mountain areas) 1 [ gone I [ 'unknown I [Present <br /> Average Annual Precipitation (inches) xxxxxXI <10 1 9 j i0-25 xxxxxxxl ?6-L0\2 <br /> ;Man-?fade conduits which increase ver^ical migration I <br /> +of teschate (i.e., septic systems, water welts, ponds) I .Mone I I Unknown !Present j <br /> ;Unique site features: Recinarge area, coarse soil, nearmy wells_ 1XXXXXXI <br /> I At least; More than <br /> None I one one <br /> S Pit Ar i,3 TJ b! /y` - ( l� <br /> o COLUMN TUTAALS>TO NTS +/(j,1D <br /> !Sample Result: (B T X OR 5) RANGE OF TOTAL POINTS49 prs or sore I (-1 - 4a pts [ 40 pts or less I <br /> 3 i X e 41 T X E. � <br /> X- ► �L M �• <br /> MAXIMUM ALLOWABLE 3-r-X-? LEVELS (PQM) 1 50, 5a� so .3 (.3 1.' AA <br /> \3 <br /> Sample esult: 7� GASOLINE 1000 I 1(30 [ 10 <br /> � -_ k) J MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> - +=t' PH D tESEi 10,000 [ 1000 [ 100 <br /> T!FOOTNOTES: Ifi 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 sail or ground water.) <br /> \1 If depth is > 5 ft. and < Z5 ft., scare 0 points_ If depth —5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points- <br /> \3 Levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppa (diesel). <br /> Vi. STAFF RECCMMENDATION/CONCLUSION �/ „ ���G - Ie Lj�CZLUI <br /> 1. Are BTX & S or TPH Concentrations > Allowable Levels 1"'Yes 1No� -ro LL C K �� <br /> 1 Z- Recommend Site Closure,Yes[ [Nol x tL*Tf Yes, Refer to Sire ,Mitigation for cvaluarianl n <br /> VII. REVIEW EVALUATION - To 3E COMPLETED 3Y A SUPERVISOR/SE.YIOR <br /> !CONCUR 'WITH STAFF RECOMMENDATION FOR CLOSURE,YESi INOI, #REF-BRED 70SITE MITIGATION FOR EVALUTATIONjTES{ INo� I <br /> 1 <br /> DATE REFERRED[ / / (DATE CLOSURE L—ETTER MAILED! <br /> NAME OF <br /> EVALUATOR! <br /> EH 23 80 (UGTWKSHT)\5/90 <br />