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SAN JOAQUIN It PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL IVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I ECORD ID S1Q®lst��/a uu <br /> DRESS 35� S '� lu s� ANK ID <br /> TANK SIZE aU® UEL TYPE Aja/ v" <br /> 11. GENERAL SITE HISTORY 4J <br /> Is permit current? as o ermit # - acility Status Code Q/ oc.Soil/GW Cont as o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank teel brgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? IresIX o ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No V 11f yes, what was repaired7 <br /> as repair done under inspection? es No ere soil samples analyzed7 es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge tastrophic long-term leakage verfill ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received les o epth to Ground Water i®® of/Year verage Annual Precipitation = 4 0-25 <br /> Site Weil(s) pe es ( o dumber & TyI rr om ub <br /> S Score S Score S core <br /> istance to WIeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition Rondition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> Minimum 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 Unknown resent <br /> verage Annual Precipitation (inches) _ xxxx <10 9 ' 10-25 xxxx 26-40_\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> nigue site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> (Muncipal=>2000 ft; domestic-->500 ft; irr/agricut tura[=present] xxxxxx None one S— one <br /> COLUMN TOTALS»>TOTAL POINTS * ✓" s ( �� �` <br /> ample Result: (B T X OR -c) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> Xf� B T X E B T X E <br /> 1 MAXIMUM ALLOWABLE B-T-X-E LEVELS {PPM) 1 50 50 50 .3 .3 1. 1. NAS <br /> ample Result: SASOLINE 1000 100 10 <br /> ��j1� <br /> 4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> CCJJ TPH"� IESEL 10,000 1000 100 <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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> _\3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels YesIx o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> )ATE REFERRED ! / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />