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SAN JOAQUIN,� NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE,r.sK DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I !F• I3. [3 <br /> AME OF FACILITY EEPS CODE <br /> �n-1-e 5 tc[<. - �e W Sh lUco(o <br /> ADRESS TANK ID # <br /> TANK SIZE UEL TYPE Qj,DGCa,�u-P ICSC'i <br /> &0 renlwM otiuc, &d <br /> It. GENERAL SITE HISTORY top 005�_o L h(QC.aact <br /> r* <br /> Is permit current? es o ermit # ility Status Code oc.Soil/GW Contes o <br /> umber of Tanks at facility Eee <br /> f Tanks(if available) ype of Tank reel IF _TFbrgl ngl Dual <br /> 111. TANK HISTORY '<rl';fttu Lckr.(4 T'il7cr�lcs5 linac-1 i+t L�iB � <br /> I <br /> as Tank tested? es o ailed precision testT es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? Pipin 1' lr LCL <br /> Ins repair done under Inspection? es o ere soil samples analyzed es to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage ver ill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es a epth to Ground Water (� of/Yea ltL verage Arcual Precipitation = 4 0-25 <br /> Site Wel (s) es I o umber & Type Irr om ub <br /> S Score 5 Score S core <br /> istance to Wells) from Tank :_____ ft; ft; —ft ft C 10 pts C pts C pts j <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition j <br /> V. site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inirrium Depth to groundwater from the Soil Sample (feet) J!5_(C) >100 1-100 Q 25-50\1 <br /> raetures in subsurface (applies to foothills or mountain areas) O None Unknown 3resent <br /> verage Annuat Precipitation (inches) xxxxxx 00 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration Q <br /> f teachate (i.e., septic systems, water wells, ponds).- y, None 1 Unknown resent I <br /> lnique site features., Recharge area, coarse soil, nearby wells: At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS-'TOTAL POINTS + 34 1 <br /> ample Result: (4 T X OR E) RANGE OF TOTAL POINTS ,9 pts or more 41 - 48 pts 40 pts or less <br /> •. FID-Zppr►� <br /> 7.4 Pips' B 7 X E B JT X E <br /> Z p prn MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 SO 50 50 .3 .3 1. 1. NA\3 <br /> ample Resul :Irbo✓ij M ASOLINE 1000 100 10 <br /> AXIMUR ALLOWABLE TPH-LEVELS.(PPM) <br /> _lowltf lIf& iso pprn IESEL 10,000 1000 100 <br /> AOTNOTES: ***If documented soit and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on LIGT -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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are-not applicable at a TPH conte tration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION IaIJ' re-.6u4±5 <br /> 1a617- Pi�1r� exc +tila#LUr? <br /> 1. Are STX & E or TPH Concentrations > Allowable Levels Yes Gtw]onlG a- <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 4 <br /> ATE REFERRED / ! ATE CLOSURE LETTER MAIL D <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSNT)\5/90 <br /> Ex 29 80 <br />