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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL .-TH DIVISION I- UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE �i I SWEEPS CODE . NAME Of FACILITY TANK ID # - 6 I ADDRESS C TANK SIZE M UEL TYPE ii. GENERAL SITE HISTORY ** Is permit current? Yes No Permit k - Facility Status Code Doc.SoiL/GW Cant YesMD)uat Number of Tanks at facility Age of Tanks(if available) Q of Tank Steel FbrgI Sngl 111- TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes No If yes, give daie(s) Was a repair made to the tank system? Yes No if yes, what was repaired? Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/E08 Type of failure/discharge catastrophic long-term leakage overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 On-Site WeIL(s) Yes No Number 8 Type [rr Dom Pub Score 5 Score S Score Distance to Wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts 0 if 0 if 0 if R condition R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet) )100 Q 51-100 25-50\1 Fractures in subsurface (applies to foothills or mAuntain 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 Unknown Present of leachate (i.e., septic systems, water wells, ponds) 0� At least) More than Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None 1 one one i � I + - COLUMN TOTALS»)TOTAL POINTS �fl Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts_ 40 pts or less B T X E B T X E MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 3 .3 1. 7. I NA\3 GASOLINE 1000 100 10 Sample Result: MAXIMUM ALLOWABLE TPH LEVELS (PPM) (� DIESEL 10,000 1000 \Yom\ l TPH FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential s currently on UGT Contamination List for soil or ground water.) analysis. (i.e., site i \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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). 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 VII. REVIEW EVALUATION - TO BE C PLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED DA74 CLOSURE LETTER MAILED / / NAME OF I EVALUATOR ' EH 23 80 (UGTWKSHT)\5/90