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SAN JOAQUIN Ol PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL,.4IVISION I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION INAME OF FACILITY I L) 7 / ��an-n0� ISWEEPS CODEI TANK ID #I TANK SIZEI (FUEL TYPE II. GENERAL SITE HISTORY Is permit current? Yes No No Failed precision test ? Permit # - Facility Status Code If Doe.Soi L/GW Cont Yes Was a repair made to the tank system? No No Number of Tanks at facility If yes, what was repaired? Age of Tanks(if available) Was repair done under inspection? Type of Tank Steel No Fbrgl Were soil samples ane Lyzed? Sngl Duet No 111. TANK HISTORY Was Tank tested? Yes YES No No Failed precision test ? Yes YES No If yes, give dates) A0114 Was a repair made to the tank system? Yes No s If yes, what was repaired? No Was repair done under inspection? Yes No Were soil samples ane Lyzed? Yes Puh No Score 10 pts if condition is met Ill Score 9 pts if condition is met TPH-G Score 5 pts if condition is met ITPH-D ft; ft; ft Pb/EDB V. Site Feature - Leaching Potential Analysis Type of failure/discharge catastrophic Long-term leakage overfill Fractures in subsurface (applies to foothills or mountain areas) unknown Nonce other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES No Depth to Ground Water YES Ref/Year Noll Average Annual Precipitation A0114 DATE REFERRED1 10-25 On -Site WeLL(s)Ye s No Number 8 Type Irr Dam Puh 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 fro Distance to Well(:) m Tank ft; ft; ft 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) Nonce Unknown Present Average Annual Precipitation (inches) xxxxxx 00 9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx Nonce At least one More than one 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 MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) a 1 T 50 X 50 E 50 a .3 T .3 X 1. E 1. NA\3 Sample Result: TPH GASOLINE MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 1000 100 10 10,000 1000 100 FOOTNOTES: "*"If documented soil arid/or ground water contamination is 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 40e 1. Are 8TX 8 E or TPH Concentrations > Allowable Levels'Yes Nof-ti� 2. Recommend Site Closure Yes No "If Yes, Refer to Site Mitigation for Evaluation S CAL- �� ' L 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 Noll DATE REFERRED1 DATE CLOSURE LETTER MAILED NAME OF EVALUATOR 11 EH 23 80 (UGTWKSHT)\5/90