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SAN JOAQUIN COY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEP,_..,, DIVISION I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION TE I// NAME OF FACILITY %G G C SWEEPS CODE DA ADDRESS Z E c g2yry TANK ID # - TANK SI2E /m.. FUEL TYPE ff�5 I Z. GENERAL SITE HISTORY r— -,/;. A- O—f. 1 Aj4� 1•� .^+•vv` v "e'er-f,�D'^� ... Is permit current? Yes N Permit # - Facility Status Code DOc.SOiL/GW Cont Yes No Number of Tanks at facility 1 Age of Tanks(if available) 7 Type of Tank Stee Fbrgl n Dual 111, TANK xISIUR1 Was Tank tested? Yes YES N NO Failed precision test ? Yes Ref/Year No If yes, give date(s) 14 Was a repair made to the tank system? Yes N DATE CLOSURE LETTER MAILED If yes, wham: was repaired? Was repair done under inspection? Yes Irr No Dom Were soil samples analyzedT Yes S C 0 R E No S C 0 R E BT S C 0 R E TPH-G Distance to Well Wallis) from Tank TPH- Pb/EDB Minimum Depth to groundwater from the Soil Sample (feet)>700 Type of failure/discharge catastrophic 51-700 long-term Leakage 25-50\1 overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes RECOMMENDATION FOR CLOSURE YES No NO Depth to Ground Water REFERRED TO SITE MITIGATION FOR EVALUATION Ref/Year /O/C.", ( U Average Annual Precipitation A= 14 10-25 On -Site WeLL(s) e LY DATE CLOSURE LETTER MAILED No Number 8 Type Irr Dom Pub 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 Distance to Well Wallis) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet)>700 Ct 51-700 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 S Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None At leastMore one s than one COLUMN TOTALS>»TOTAL POINTS lG ♦ l /%1 11/40 _ \l Sample Result: (B T X OR E) - ND RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts p eas MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 B .3 T .3 I X 1. E 1. NA\3 Sample Result: N D TPH GASOLINE MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 1000 100 10 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 BT%&E are not applicable at a TPH concentration of 10 Ppm (gasoline) or 100 ppm (diesel). STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 E or TPH Concentrations > Allowable Levels •Yes No 2. Recommend Site Closur Ye I No •If Yes, Refer to Site Mitigation for EvaLuat J 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCURt111TH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR