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SAN JOAQUIN C&P.01'Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAV4 DIVISION UGST WORKSHEET FOR SITE CLOSURE EVALUATION NAME OF FACILITY TANK SIZE {�J—� �. FUEL TYPE [i. GENERAL SITE HISTORY its permit current? Yes No Number of Tanks at facility III. TANK HISTORY TANK ID # t # - facility Status Code Doc.Soil/GW Cont Yes N Age of Tanks(if available) Type of Tank Steel Fbrgl Sngll Dual IWas Tank tested? Yes No No Depth to Ground Waterfs Failed precision test ?Yes Ret/Year DATE REFERRED No A= If yes, give dates) 10-25 Was a repair made to the tank system? Yes No If yes, what was repaired? Uas repair done under inspection? Yes No 5 C 0 R `c Were soil samples analyzed? Yes No S C 0 R E BTXE TPH-G TPH-01 Pb/EDB Type of failure/discharge catastrophic long-term leakage O overfill Fractures in subsurface (applies to foothills or mountain areas) unknown other: IV. REMOVAL HISTORY (ATTACH INSP€CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes i YES NO No YES Depth to Ground Waterfs NO Ret/Year DATE REFERRED Average Annual Precipitation A= 14 10-25 On -Site VeLL(s) Yes No Number & Type Irr Dom Pub 5 C 0 R `c 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 'Distance to WeLl from Tank ft; ft; ft jV. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 O 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) Unknown Present 'Average Annual Precipitation (inches) xxxxxx9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration lof leachate (i.e., septic systems, water wells, ponds)O rNone Unknown Present iUnique site features: Recharge area, coarse soil, nearby watts. xxxxxx At least one More than one ! COLUMN TOTALS»>TOTAL POINTS t O ' 2 + ;Sample Result: (8 T X OR E) �R--O-OZB, T *.#Lk E # a- : Y % 3 RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pis or less MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1 E 1 1. 9A\3 .S Wesu t. ` Z7U Z L7 TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 100 10 DIESEL 10,000 1000 100 (FOOTNOTES: >" If documented soil and/or ground water contamination is present, do not comptete the Leaching potentlat 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasotine) or 100 ppn (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPN Concentrations > AtlowabLe Levels *Yes No i2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation V:I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED �MFOR AjDATE v CLOSURE LETTER MAILED l/ / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 J