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SAN JOAQUIN COCRTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL-A� DIVISION DATE I UGST WORKSHEET FOR SITE CLOSURE EVALUATION SWEEPS CODE (NAME OF FACILITY TANK ID # 1 - nCiLQ>>3 TANK SIZEI'f) C)tiU II. GENERAL SITE HISTORY els permit current? Yes V ;Number of Tanks at facili Ill TANK HISTORY FUEL Permit 9163 3 Facility Status Code O� Doc.soil/GW Cont Yes N / Age of Tanks(if available) ,17 ,✓Q_ Type of Tank ;teal Fbrgl Sngl Dual Was Tank tested? Yes111 No REFERRED TO SITE MITIGATION FOR EVALUATION Failed precision test ? Yes Ref/Year No If yes, 14 Was a repair made to the tank system? Yes No If yes, what was repaired? No Was repair done under inspection? Yes No Were soil samples analyzed? Yes No 5 C BTXE TPH-G TPH-0 5 C Pb/EDB ;Distance to Wells) from Tank Type of failure/discharge catastrophic 0 R E long-term leakage 0 R E overfill 0 R E unknown other: IV REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/CULULI UAiA run LcA�n.n.. .. -•---- Soil Samples Received Yes NO No REFERRED TO SITE MITIGATION FOR EVALUATION Depth to Ground Water ZU Ref/Year w10 Average Annual Precipitation A= 14 10-25 On -Site Well(s) Yes No Number 8 Type Irr Dam Pub 5 C Score 10 pts S C Score 9 pts 5 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 condi Sian fs met ;V. Site Feature - Leaching Potential Analysis IMinimim Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50V Fractures in subsurface (applies to foothills or mountain areas) None a Unknown Present :Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 ,Man -Made conduits which increase vertical migration a Unknown Present jof leachate (i.e., septic systems, water wells, ponds) None j jUnique site features: Recharge area, coarse soil, nearby wells. At least More than Xxxxxx None one one 0 COLUMN TOTALS>»TOTAL POINTS :Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less 7 MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 11 50 50 50 1. 1- NA\3 Sample Result: GASOLINE 1000 100 10 p '1{4E�= -I MAXIMUM ALLOWABLE TPH LEVELS (PPM) � TPH DIESEL 10,000 1000 100 FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leacning potenn aL analysis- (i.e., site is currently an 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 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 YesI V1 No 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 l/ / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 v