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SAN JOAQUIN CCO PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA*IVISION 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITYxyl / _ �'7 SWEEPS CODE ADDRESS '- J S TANK 10 # J TANK S12E D Q L) FUEL TYPE � ii. GENERAL SITE HISTORY re Vs A-Lly�yrniollo tD�p7✓L� Is permit current? Yes No Permit # - Facility Status Code - Doe.Soil/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) , Type of Tank Steel Fbrgl Sngl Dual 111. TANK 0 C• �� G�Y1 �iYes Was Tank tested? Yes No Failed p inion 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 No Were soil samples analyzed? Teal No BTXE TPH-G TPH-O Pb/EDB Type of failure/discharge catastrophic long-term leakage overfill unknown other: IV. 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 Well(S) Yes No Number & Type Irr Daa Pub S Score S Score S Score Distance to WeLI(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) �� ,�+�G, = D >100 51-100 O 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 q Unknown Present 'Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one COLUMN TOTALS>»TOTAL POINTS d O + A7 + Q = 3 Sample Result: (B T % OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 Less Si A1+ �. D. Sa q it A), D. B T % E B T X E MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sade Result: GASOLINE 1000 100 10 S5 = f}li P)' MAXIMUM ALLOWABLE TPH LEVELS (PPM) .5 ;7 AILPIIhPH DIESEL 10,000 1000 100 FOOTNOTES: ***If documented soil and/or grourd water contamination is present, do not complete the le r a 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, p \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm"(Lgasoline) or 100 ppm (diesel). 3 3 .1.'J` • VI. STAF RECOMMENDATION/CONCLUSION S-r-�—C %Cj 1. Are HTX & E or TPN Concentrations > Allowable Levels *Yes No ne cYL(�Tj; S a '/C"� L 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BEC PLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES LINOI REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90