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SAN JOAQUIN WTY PUBLIC HEALTH SERVICES/ENVIRONMENTALL HEAWDIVISION AT <br /> 1 y UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY BEEPS,CODE% <br /> ANK 1 <br /> DDRESS LA-ie.` T� Sft�c�C{ rl Cly <br /> ANK SIZE 5 QQQ �Q UEL TYPE vh <br /> 11. GENERAL SITE HISTORY ** <br /> 1s permit current? es o ermit # acility Status Code �� oc.Soil/GW Con es o <br /> Number of Tanks at facility g ge of Tanks(if available) UnKv1 Vype of Tank t'eel IrbrgL <br /> ngl Dual <br /> ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test? es o f yes, give dates) <br /> as a repair made to the tank System? IYes Na ii�±f yes, what was repaired?, <br /> ns repair done under inspection? es N o ere soil samples analyzed? es TXE -G -D b/EDt3 <br /> ype of faiture/discharge atastrophic long-term leakage verf M I own I thea: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year Sprv+j <br /> verage Annuat Precipitation = 4 10-25 <br /> Dn-Site Wetls) es o .; umber & Type Mori#oi^" om ub <br /> S core S core S core <br /> istance to Wells) from Tank __ ft; -ft; ft C 0 pts C pts C pts <br /> '0 if 0 if o 'f <br /> R condition R condition 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)*j_(cj 3 C)' )100 1-100 -5. 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) © None Unknown 3resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 XXXXXXX 26-40\2 <br /> E an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inlque site features: Recharge area, coarse sail, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TQTAL POINTS �� + , + b 3B <br /> ample Result: (B T X OR E) . RANGE OF TOTAL POINTS ,9 pts or more 41' - 48 pts 40 pts or less <br /> B T X E S T X E: <br /> 0.41 A4�'h T$ MAXIMUM ALLOWABLE B-T=X-E LEVELS (PPM) -1 50 50 50 3 3 1: 1. NA\3 <br /> "ample Result: ASOLINE 1000 100 10 <br /> 'r:� 1)5(70•??*, 1AXIMUM ALLOWABLE TPH LEVELS.(PPM) <br /> -f-lb - 17-0- TPH IESEL, 10,004 1,000 100 <br />'4FOOTNOTES: *t*If documented soft 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 1f 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 STXBE are not-appticable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations -Allowable Levels t Yes 0 y �Y1�ynQ <br /> 2. Recommend Site Closure 1Yes a 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 EFEARED TO SITE MITIGATION FOR EVALUATION• ES. 0 <br />€ ATE REFERRED / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> E .VALUATOR <br />�. EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />