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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH D1Vi5jOH ATE ��O <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> EEPS:CODE <br /> AME OF FACILITY �Nn�eYlh� �Vv1rx ��p(pO l� <br /> DORESS � (C) LOw�� �V'CIYYta11.'_0 TANK i0 # �py n}� t� <br /> TANK SIZE I PumpUEL TYPE �0.5dilna <br /> 11. GENERAL SITE HISTORY ** <br /> Is permit current! es o ermit # acility Status Code 5 oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) UYIKh ype of Tank teel Fbrgl ngl Dual <br /> I1I, TANK HISTORY <br />` as Tank tested? es ailed precision test? es p f yes, give dates) <br /> as a repair made to the tank system? IYes No f yes, what was repaired? <br /> ns repair done under inspection? es 90 ere soil samples analyzed? es o T,XE G H-D b/EDQ <br /> ype of failure/discharge atastrophic long term leakage verfiII noun they: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water t of/Year ;1t$(o verage Annual Precipitation = 4 10-25 <br /> Site Well(s) es I V+o /, umber & Type om ub <br /> - S 3core 5 Score 5 care <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> f inimum Depth to groundwater from the Soil Sample (feet) 4rD— # t )100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 10 None unknown resent <br /> verage Annual Precipitation (inches) KAXXXX <10. 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration ��yy <br /> f teachate (i.e., septic systems, water wells, ponds) None —1. Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells: f At leastore a than <br /> xxxxx None one 5 one, <br /> COLUMN TOTALS»)TOTAL POINTS to 3e <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more. 41 - 48 pts 40 pis or less <br /> $: 1.5(a PPM T-3 B T X E. a X EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 31.1 <br /> 3 1. 1. NA\3 <br /> "ample Result: ASOLINE 1000 100 10 <br /> 510. S (PPM) <br /> Ih ) P P TPH-a�q9 AXlMUM ALLOWABLE TPH LEVELS 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 snit 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 appticable at a TPH concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > AtLbwab�Levetss I o � <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V1I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br />{ AME OF <br /> :VALUATOR <br /> „ . <br /> EH 23 80 (UGTWKSHT)\S/90 <br /> EH 29 80 , <br />