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SAN JOAQUIN Tet..tY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL. DIVISION <br /> 1.`' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 1//, ,y v <br /> ryAeE OF FACILITY �P� f EEPS CODE <br /> tDORESS0 co, �/ •f�—y) aNK 10 0 <br /> Ir ANK SIZE S�V UEL TYPE �/ /, <br /> /�{ <br /> r <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? as o ermit N acility Status Code ,,.Soil/GW Conc es o <br /> umber of Tanks at facility he of Tanks(if available) ype of Tank reel Fbrgl ngl Oual <br /> III. TANK HISTORY <br /> :as Tank tested? Iras o ailed precision test ? as o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> Pas repair done under inspection? Fi ere soil samples analyzed? es !o TXE PM•G Fi b/E08 <br /> ype of failure/discharge atastrophic lolg-term leakage verfill known cher: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received ifas o eprh Co Ground Water t^? / of/Tear i1�L � ( , verage A Precipica Cion = 4 10.25 <br /> •Si Ce Welts) If <br /> es o Lmxer 8 Type Irr am I b <br /> 5 core S core S core <br /> Distance :o We(L(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if O 'f <br /> R ondition R ondition R ondicion <br /> Site Feature - Leaching Potential Analysis is met E is met = 's met <br /> Minimum Depth to groundwater from the Soil Sample (feet)1G_VQ�16 >100 1.100 I25-50\1 <br /> �ractures in subsurface (applies to foothills or mountain areas) All None Unknown resent <br /> overage Annual Precipitation (inches) ( xxxxx <10 9 110.25 xxxxxxx 26.40\2 <br /> ,n-Made conduits which increase vertical migration /� <br /> P( leachate (i.e., Septic systems, water wells, ponds) /v None now reS Mt <br /> Inicue site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> $ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 41 48 PCs 40 PCs or less <br /> BIT X 'c 3 % <br /> G MAXIML14 ALLOWABLE 3- LEVELS (PPM) 1 50 50 50 ( .3 .3 1, 1, NA\3 <br /> -ample Result: SOLINE 1000 I 100 10 <br /> AX IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH _ IESEL 10,000 1000 100 <br /> COTNOTES: "If documented soil and/or ground water contamination is present, do not complete the Ieach ing pot enrial <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If death is > S ft. and < 25 ft., score 0 point s'. ,If depth <=5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel . <br /> VI. STAFF 3EC0lMENOATION/CCNCLUSlON <br /> 1, Are 3TX 3 "c or TPH Concentrations > Allowable levels Yesl �fo <br /> I2. Recommend Site Closure (Yes �o� If Yes, Refer to Site Mitigation for Evaluation OV <br /> :f. REVIEW "c VALUATION - TO BES COMPLETED 3Y A SUPERVISOR/SENIOR <br /> .CHCUR WITH STAFF RECCMMENDATICN FCR CLOSURE 14 ES OI PEFERREO TO SITE :<ITLGATICN FCR EVALUATION IVES �o <br /> aTE REFERRED / ,� / /4 ATE CLOSURE LETTER MAILED <br /> AME CF <br /> .VALUATCR <br /> EH 23 30 (UGTWKSHT)\5/90 <br /> . -9 :0 <br />