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SAN JOAQUIN &� 4Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL n DIVISION I.NAME OF FACILITY UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE SWEEPS CODE ADDRESS TANK ID # 31 - TANK SIZE FUEL TYPE •�1 11. GENERAL SITE HISTORY w** is permit current? Yes No Permit # - Facility Status Code Doc.SOi(/GW Cont YeSF No Number of Tanks at facility Age of Tanks(if avaiLabLe)j Type of Tank Steel Fbrgl Sngl Dual III. TANK HISTORY Was Tank tested? Yes No Failed precision tefiYesjNolf yes, give date(s)Was a repair made to the tank system? Yes No ed?Was repair done under inspection? Yes No WeYes No BTXE TPX-G TPH-D Pb/Type of failure/discharge catastrphic Long-tunknown Iother: V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 On-Site Wells) Yes No Number 8 Type Irr Dan Pub Score S Distance to WellS Score S Score Wells) 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) >10051-100 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. Q At least More than xXxxxx None �. II one one COLUMN TOTALS»)TOTAL POINTS + U S + Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 141 - 48 pts 40 pts or less B T X E B T X E _ MAXIMUM ALLOWABLE 8-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPN 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 BTXBE 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 Concentration Allowable Levels *Yes No 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation I. 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 / / DA E CLOSU LETTER MAILED NAME OF EVALUATOR EH 23 80 1UGTWKSHT)\5/90