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/ SAN JOAQUIN COUNTY PUBLIC HEALTH.SERVICES/ENVIRONMENTAL TH DIVISION <br /> q <br /> 1. UGST � <br /> AWORKSHEET FOR SITE CLOSURE EVALUATION ATE 2•Zy . <br /> AME OF FACILITY l✓1 L(�!'vlt�l EEPS CODE <br /> ODRESS ��� 4 YJO✓' �- i� �j rj� �3ITANK ID # 3�- 1 L3Z~ O L4 <br /> ANK SIZE I 1Q,060n-V JFUEL TYPE I UfjCgAd4 <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o rmit # acility Status Code 6k oc.Soil/GW C es to <br /> umber of Tanks at facility ge of Tanks(if available} j� r� ype of Tank Leel rgl ngl Dual <br />- <br /> Ill. TANK HISTORY rerrwv a l 2 V <br /> 'as Tank tested? es a ailed precision test ? es o If .yes, give date(s) <br /> Jas a repair made to the tank system? IYes No f yes, what was repaired? <br /> ns repair done under inspection? es o re soil samples analyzed? es Io TXE PH-G I PH-D b/EDB <br /> r ype of failure/discharge atastrophic long-term leakage verfill noun ther: <br /> 1V• REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received es o epth to Ground Nater G J of/Year g b verage Annual Precipitation = 4 10-25 <br /> •Site Wali(s) es o umber 8 Type Irr as ub <br /> S core 5 core S core <br /> istance to Wells} from lank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> R condition R conclition R ondition <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) ti$.. =�a >100 1-100 D 25-50\i <br /> Eractures in subsurface (applies to foothills or mountain areas) i d None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 KXXXXXX 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 5resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 10 + Z-- + D <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> U I N°O Srx <br /> 02 t4D •p a T x E B T x 1 <br /> Pr's MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 3 i. 1. NA\3 <br /> Sample Result; ASOLINE 1000 100 10 <br /> ()I 14.0Pf W1 4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Ul- 51q H 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 /> \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 BTX8E 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 <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 /> DNCUR WITH STAFF RECOMMENDATION FOR'CLOSURE ES 0 EFERREQ TO SITE MITIGATION FOR EVALUATION ES O <br /> RTE REFERRED / ! - ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 IID (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />