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SAN JOAOUIN JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEi H DIVISION ATE <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> WEEPS CODE �� r <br /> AME OF FACILITY m . rc 70'u S'4 �, &— c!c°.�i " <br /> ANK ID # <br /> DRESS 000 Ar 14 <br /> TANK SIZE 1500,1 UEL TYPE 12_ q <br /> I1. GENERAL SITE HISTORY "* <br /> is permit current7 es o ermit # - scility Status Code 7 oc.Soil/GW Cont es o <br /> type of Tank teel Fbrgl ngl Dual <br /> umber of Tanks at facility � ge of Tanks(if available) �F <br /> III. TANK HISTORY <br /> F.. Tank tested? es o ailed precision test 7 es o If yes, give dates) <br /> typeof <br /> ir made to the tank system? es No t/ f yes, what was repaired? <br /> r done under inspection7 es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ailure/discharge I atastrophic long-term leakage verfilL nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es V o epth to Ground Water '-S of/Year a3 verage Annual Precipitation = 4 0-25 <br /> )n-Site Well(S) IYes o umber & Type I <br /> S core 5 Scare Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts Cfpts <br /> 0 if 0 if 0 <br /> R condition R rondition R ondition <br /> Site Feature - Leaching Potential Analysis E 9s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)r - u' >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> %verage Annual Precipitation (inches) KXXXXX <10 9 10-25 KXXXXX. 26-40L < <br /> an-Made conduits which increase vertical migration ; None Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> nique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> n + `� <br /> COLUMN TOTALS»>TOTAL POINTS �C? + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts <br /> �y40 pts or less <br /> /fp'q 13 -e— pt]S T X E B JT X E <br /> 7/T 7^f�pf MAXIMUM ALLOWABLE B-T-X-E LEVELS (P1 50 50 50 .3 .3 1. 1. NAL <br /> t:f bc•ir�e A50LINE 1000 100 10 <br /> Sample Resul <br /> AXIS ALLOWABLE TPH LEVELS (PPM) <br /> 2z/00 > TPH IESEL 10,000 1000 140 <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 /> 11 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. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 140 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <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 /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E5 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED 1 / <br /> AME OF <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />