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SAN JOAQUIN CCn,n i PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL n. JIVISION 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATIONDATE -7 _Z _9Lf NAME OF FACILITY vt � d,V% SWEEPS CODE M Z3 ADDRESS ll - ,�y,�, TANK ID # TANK SIZE ` V FUEL TYPE Y u, 1 11. GENERAL SITE HISTORY set Is permit current? Yes No Permit # - /�-�; Z Facility Status Code 0 D00.SOLI/GW Cont Yes No Number of Tanks at facility � Age of Tanks(if available) 2 p (5 Type of Tank Steel Fbrgl Sngl Dual III. TANK HISTORY Was Tank tested? Yes No Failed precision test 7 Yes No V If yes, give date(s) Was a repair made to the tank system? Yes No If yes, what was repaired? Uln /i/; Was repair done under inspection? Yes No Were soil samples analyzed? Yes No STXE TPH-G TPH•D Pb/EDB TYpe of failure/discharge catastrophic long-term leakage overfill unknown other: IV. REMOVAL HISTORY (ATTACH INS P#TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes N Depth to Ground Water I D Ref/Year r; 8 Average Annual Precipitation A= 14 10-25 On-Site WetL(s) Yes No 14 Number & Type Irr Dom Pub S Score 5 Score S Score Distance to WeLL(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) /C) (Z1�2' -100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 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. At least More than XxxxxX None one one air / mntfi� C4 - - COLUMN TOTALS>>>TOTAL POINTS + + - SanpLa Result: (B T % OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less NlceS{ are; 7�h1 85ff" )( "12OOep`A B T % E B T X E MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. I. NA\3 Sample Result: GASOLINE 1000 100 10 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 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. S7AF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPN Concentrations > Al owable Levels 'Yes No T= E: ISaFFb JJ G(�f 2. Recommend Site Closure Yes No `If Yes, Refer to Site Mitigation for Evaluation x lBD A ' VII. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR , 1�71f= U l(/ M CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INC[' REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / 2/ DATE-CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90