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SAN JOAQUIN by PUBLIC HEALTH SERVICES/ENVIRONMENTAL M011H DIVISION I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITYt _ SWEEPS CODE r ADDRESS )TV c TANK ID # r2C TANK SIZE FUEL TYPE ..CENERAL SITE wICTORY ; permit current? Yes No No Failed precision test ? Permit # - Facility Status Code 14 Was a repair made to the tank system? Doc.Soil/GW Cant Yes If yes, what was repaired? No tuber of Tanks at facility No Dom Age of Tanks(if available) Yes Type of Tank Steel Score 9 pts Fbrgl Score 5 pts Sngl ft; ft; ft Dual III. TANK HISTORY Was Tank tested? Yes No HDepth Failed precision test ? Yes Ref/Year No if yes, give date(s) 14 Was a repair made to the tank system? Yes No If yes, what was repaired? Was repair done under inspection? Yes Irr No Dom Were soil samples analyzed? Yes No Score 10 pts BTXE Score 9 pts TPH-G Score 5 pts TPH-D ft; ft; ft Pb/EDB Type of failure/discharge if condition is met catastrophic if condition is met long-term Leakage if condition is met overfill V. Site Feature - Leaching Potential Analysis unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING PU[hNiIAL ANALTbia) Soil Samples Received Yes No HDepth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 On -Site WeLI(s) Yes No Number 8 Type Irr Dom Pub S C Score 10 pts S C Score 9 pts S C Score 5 pts Distance to Wells) from Tank ft; ft; ft 0 R E if condition is met 0 R E if condition is met 0 R E if condition is met V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration None 9 Unknown Present of leachate (i.e., septic systems, water wells, ponds) Unique site features: Recharge area, coarse soil, nearby wells. None /� -I At least one More than one xxxxxx COLUMN TOTALS>>>TOTAL POINTS + + _ Sample Result: (B T X OJE) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less B T X E 1. NA\3 AXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1. GASOLINE 1000 100 10 Sample Result: MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 DIESEL 10,000 1000 TPH ***If documented soil and/or ground water contamination is present, do not complete the teaching potential FOOTNOTES: analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) if depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do not use table. %1 \2 If precipitation is > 40 inches, score 0 points. applicable at a TPH concentration of 10 ppm (gasoline) or too ppm (diesel). \3 Levels for BTXBE are not VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation 111111 VI'. . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION DATE REFERRED / / DATE CLOSURE TTER A D NAME OF EH 23 80 (UGTWKSHT)\5/90