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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH' K ISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY G S SWEEPS CODE 21 <br /> _70DRESS 'aj �O 14C �(� , A-- ID # O ' <br /> TANK SIZE -17 �yU UEL TYPE <br /> 11. GENERAL SITE HISTORY *: <br /> [s permit current? es o X it # - acility Status Code 3/ . oil GW Cont es o <br /> �j umber of Tanks at facility .eq— of Tanks(if available) of Tank ISteel Fbrgl LpngL Dual <br /> III. TANK HISTORY ,�/ <br /> Jas Tank tested? es o iced precision test T es /r o I If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es I No e soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Pype of failure/discharge atastrophic long-term leakage verfitl nown ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION PORT FOR SITE DETAILS/COL CT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water Q e /Year age Annual Precipitation = 4 0-25 <br /> -Site Well(S) es < o P18er & Type Irr om .j ub <br /> S core S core S core <br /> istance to Wetl(s) from Tank C' ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E I is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-501 <br /> © ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration Unknown resent <br /> Df leachate (i.e., septic systems, water wells, ponds) None <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> None one one <br /> ® COLUMN TOTALS>>>TOTAL POINTS + 3 V + <br /> Sample 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 JE- B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50. 50 .3 .3 1. 1. NAI <br /> ampte Result: <br /> ASOLINE 1000 _ 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH lESEL 10,000 1000 <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 /> 12 If precipitation is > 40 inches, score 0 points. ppm (gasoline) or 100 (diesel). <br /> 13 Levels for BTX&E are not applicable at a TPN concentration of 10 Ppm <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> E21 Are BTX & E or TPH Concentrations > Allowable Levels Yes 7F <br /> Recommend Site Closurees o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ------------ <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />