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SAN JOAOUIN CCL'17Y oUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION C ,. U' WORKSHEET FOR SITE CLOSURE EVALUATION DATE — NAME OF FACILITY S (` / ,,'A _PS CODE l No permit current? Yes TANK TO X No Permit tl ADCRESS - / Facility Status Code �; Doc.Soi l/GW Cont Yes TANK SIZE No FUEL TYPE --sto Off r / GENENAL Slit al>�Vaw No Failed precision test 7 Yes Ref/Year No If yes, give date(s) / Was a repair made to the tank system? ,.. No permit current? Yes Yes No Permit tl ") C� - / Facility Status Code �; Doc.Soi l/GW Cont Yes pts condition is met No rater of Tanks at facility ft; ft; ft / Age of Tanks(if available) 3 long-term leakage Type of Tank Steel Fbrgl Fractures in subsurface (applies to foothills or mountain areas) Sngl Dualvj Ill TANK HISTORY Was Tank tested? Yes RECOMMENDATION FOR CLOSURE No Failed precision test 7 Yes Ref/Year No If yes, give date(s) / Was a repair made to the tank system? Yes No If yes, what was repaired? Was repair done under inspection? Yes Irr No Dom Were soil samples analyzed? Yes No Scare 10 pts if condition is met BTXE pts condition is met TPH-G TP" -D PI EDB ft; ft; ft Type of failure/discharge V. Site Feature - Leaching Potential Analysis catastrophic long-term leakage overfill unknown Fractures in subsurface (applies to foothills or mountain areas) other: 1V REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECi DAIA LUA LEA'nweu 'Soil Samples Received Yes RECOMMENDATION FOR CLOSURE No Depth to Grand Water% 1 Ref/Year G' Average Arcual Precipitation A- 14 10-25 On -Site Well(s) Yes No Huiber L Type Irr Dom Pub S C 0 R E Scare 10 pts if condition is met S Score C 9 0 if R E pts condition is met S C 0 R E Score 5 pts if condition is net Distance to Well(s) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Minim Depth to groundwater from the Soil Saaple (feet) ? C, >100 51.100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) C> 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 walls, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. Xxxxxx None At Least one More then one COLUMN TOTALS»>TOTAL POINTS ! C) � .37 Sanpte Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less IUXIMLIN ALLOWABLE B -T -%-E LEVELS (PPM) B T 1 50 X 50 E 50 B .3 T .3 X. 1. E 1. NA\3 Sample Result: �'/ ) il/� t MAXIMUM MIM ALLOWABLE TPN LEVELS (PPM) GASOLINE 1000 4 100 10 DIESEL 10,000 1000 100 FOOTNOTES: If documented soil and/or ground water contamination is present, do not lets 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 STXdE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION < 1. Are BTX i E or TPH Concentrati > All able Levels -Yes VINO - 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for "Evaluation VII REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISCR/SENICR 7� -AA STw� . C�.. JIfiLKJ CCNCJR WITH STAFF RECOMMENDATION FOR CLOSURE YES WOI REFERRED TO SITE MITIGATION FOR EVALUATIOWIYESI NOI DATE .REFERREDI / / DATE CLOSURE LETTER MAILED NAME CF EVALUATOR EH Z3 80 (UGTWKSHT)\5/90