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SAN JOAQUIN * PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA VISION <br /> �• UGST WORKSHEET FOR SITE CLOSURE EVALUATICN ATE <br /> AME OF FACILITY n Glf�Cef EPS CODE <br /> ADRESS r�j 56 �Ci/JTL� �P �Cl - ANK ID 9 <br /> TANK SIZE /n O UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 as 10. 1 <br /> ermit 9 - acflity Status Code oc.Soil/Gw cont es o <br /> ager of Tanks at facility Be of Tanks(if available) .4k ype of Tank teal rgl ngl Dust <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es a If yes, give date(s) <br /> as a repair made to the tank system? es No /I f yes, what was repaired7 <br /> as repair done under inspectim7 as o / ere soil samples analyzed? es o f PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophie tmg-tern Leakage verfill n noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Receivedes o epth to Ground Water 3 of/Tear L; verage Annual Precipitation 4 0-25 <br /> •Site Well(s) es ) o I umber 8 Type I Irr I ub <br /> S core S Score S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 1 0 if 0 f <br /> R onditim R condition R andition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown resent <br /> %verage Annual Precipitation (inches) KXXxxX <10 ® 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration _ <br /> f leachate (i.e., septic systems, water wells, ponds) None -Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby welts. At Least iore than <br /> xxxx None 7 we one <br /> COLUMN TOTALS>»TOTAL POINTS + 17 i <br /> ample Result: (B T X OR E %/a RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 43 /r9,0ad gY <br /> Poo <br /> B T X E B T X E <br /> T 21J�OGYJ X �OY On c MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 501; 1. NA\3 <br /> ample Result: ASOLINE 1000 100 70 <br /> �AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPN IESEL 10,000 1000 700 <br /> OOTNOTES: ---If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis- (i.e., sf to is cur T Cm[amination List for soil or ground water.) <br /> \1 if depth is >,5 ft. end < 2,5 ft., core 0 points If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCFMENOATION/CCNCLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levets Yes I <br /> o T <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 /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATICN FOR EVALUATION ES <br /> ATE REFERRED / `7 / � ATE CLOSURE LETTER MAILED <br /> 1AME Of <br /> :VALUATOR <br /> CH 23 30 (UGTWKSHT)\5/90 <br />