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SAN JOAOIIIN CmFITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA D1ViSJON AT ' <br /> I. , UGST WORKSHEET FOR SITE CLOSURE EVALUAT"ION Q a& Q <br /> y SWEEPS ` <br /> AME OF FACILITY ��.��d, �Y�-�� CODE 1�`�'n ) <br /> %DDRESS -4-c(jr) Lower r a -r0.w-0-n+t> PLO L.+-1 TAN ID # 3 <br /> ANK SIZE 5WO UEL TYPE un <br /> 11. GENERAL SITE HISTORY <br /> Is permit currentl es o ermit # acitity status Code r]f oc.SoiI/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) u nkh ype of Tank reel Fbrgl ng l' Dual <br /> ti <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 if yes, give date(s)' <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil Samples analyzed' es Jo TXE H-G' H-D �b/ • <br /> ype of failure/discharge atastrophic Long-term teakag <br /> e verfiEE n then. <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> of/Year h g(i verage AhnuaI Precipitation = 4 10-25 <br /> oil Samples Received es o epth to Ground Water �5 sp 19 <br /> r�; <br /> Site Weil(s) es o umber & Type A1on;1 om ub <br /> S Score S Score. S core <br /> istance to Wetl(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if O if 0 if <br /> R condition R condition R pondition <br /> Site Feature - Leaching Potential.Anatysis E is met E is met E •s met <br /> inimum Depth to groundwater from the Soil Sample (feet)45-15 P30' >100 1-100 5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) D rN <br /> ne Unknown resent <br /> verage Annual Precipitation (inches) xxxxx0. 9 10-25 xxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration Q <br /> 4 f leachate (i.e., septic systems, water wells, ponds) ne k Unknown resent <br /> )nique site features: Recharge area, coarse soil, .nearby weLls: At least 4ore than <br /> :.. xxxxx None one J one <br /> II � <br /> COLUMN TOTALS>>>TOTAL POINTS 1,C) 1� U <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41, 48 pts. 44 pts or less <br /> $. 3.d pip v%- —I-E; G T X E B T X E <br /> $; Z•� may"' T(0 MAXIMUM ALLOWABLE A-T-X-E LEVELS (PPM) 1 50 50 .50 ,3 3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1D00 100 10 <br /> -5 4,810.PPM iAXIMUM ALLOWABLE TPH LEVELS.(PPM) <br /> T-Lp 4,+q'DIESEL,.Trx+r TPH OS 10,000 1000 100 <br /> OOTNOTE$: ***If documented soil and/or ground water contamination is present; do not complete the leaching potential <br /> E 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 BTX&E 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 > Atlowabte Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />€ V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR <br /> I .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 0 EFERREQ TO SITE MITIGATION FOR EVALUATION ES �0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / 1 <br />{ qAME OF - <br /> VALUATOR <br /> 4 EH 23 80 (UGTWKSHT)\5/90 ` <br /> EH 29 80 <br />