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OF FACILITY TANK SIZE it. GENERAL SITE HISTORY Is permit current? Yes ;Number of Tanks at facil III. TANK HISTORY SAN JOAOUIN %..NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE,fI DIVISION UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE — ._.rt SWEEPS CODE a / D`7/y�..� TANK ID .! iEL TYPE Dl 5,p. -v' 5 / Permit # - Facility Status Code 6 Dac.Soil/GW Cont Yes N Ace of Tanks(if available) „� Type of Tank Steel IFbrgl Sngl Dual !Was Tank tested? Yes NO No YES Failed precision test ? Yes Ret/Year No ILIf yes, give date(s) A=114 ,Was a repair made to the tank system? Yes NO Yes If yes, what was repaired? No .as repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPN -G S C 0 R E TPN -D S C 0 R E Pb/EDB . D'stance to WeLL(s) from Tank !Type of failure/discharge catastrophic Minimum Depth to groundwater from the Sail Sample (feet) 340— tong -term leakage >100 overfill` unknown 25-50\1 other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING PUTENIIAL ANALTi1>) Ds Ds.? A5 Soil Samples Received Yes NO Na YES Depth to Ground Water NO Ret/Year Average Annual Precipitation A=114 DATE CLOSURE LETTER MAILED 10-25 �On-Site Wetl(s) Yes No Number & Type Irr Dam Pub S C 0 R E Score 10 pts if condition is met S C 0 R E Score 9 pts if condition is met S C 0 R E Score 5 pts if condition is met . D'stance to WeLL(s) from Tank ft; ft; ft IV. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Sail Sample (feet) 340— >100 51-100 25-50\1 !Fractures in subsurface (applies to foothills or mountain areas) ® None Unknown Present Average Arcual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Nan -Made conduits which increase vertical migration .of leachate (i.e., septic systems, water wells, ponds) / 0 None Unknown Present iUnique site features; Recharge area, coarse soil, nearby wells. xxxxxx None At least ane More than one PS _3 = E5 TEX = X -'a, A Da 55 COLUMN TOTALS>»TOTAL POINTS ` + 'Sample Result: (B T X OR E) 41 ,ps %� .BT EX RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts 40 pts or less MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 B .3 T .3 X E 1. 1. NA\3 Sample ! Result: = N b G TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 100 10 DIESEL 10,000 1000 100 .FOOTNOTES: --*If documented soil and/or ground water contamination fs present, do not complete the leaching potential analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppin (diesel). 111. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Concentrations > Allowable Levels `Yes No 2. Recommend Site Closure Yes No X, `If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME OF EVALUATOR EH 23 a0 (UGTWKSHT)\5/90