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SAN JOAQUIN COE„TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY SWEEPS CODE ADDRESS O TANK 10 * 3 - TANK SIZE FUEL TYPE II. GENERAL SITE HISTORY its permit current? Yes No Permit # Pf, - a3 Facility Status Code Doc.Soi L/GW Cont Yes No 'Number of Tanks at facility 2 `Age of Tanks(if available) Type of Tank Steel FbrgL Sngll Dual 111. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes 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? Yes No BTXE TPH-G TPH-0 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-114 10-25 i On-Site Wells) Yes No Num Well ber 8 Type Irr Dam Pub S Score S Score S Score Distance to Wels) from Tank ft; ft; ft C 10 pis 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) >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Cl Unknown Present 'Average Annual Precipitation (inches) xxxxxx <10 9 10.25 xxxxxxx 26-40\2 iMan-Made conduits which increase vertical migration lof leachate (i.e., septic systems, water wells, ponds) None Unknown Present i iUnique site features: Recharge area, coarse soil, nearby wells. /) At least More than xxxxxx None IA1 one one i COLUMN TOTALS»>TOTAL POINTS Z�(� + � o �� ;Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less I B T X E B T X E • Y MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) j�/ •Q • TPH DIESEL 10,000 1000 100 FOOTNOTES: ***If documented sail 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes Na *If Yes, Refer to Site Mitigation for Evaluation V:I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES1,--K01 i REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE 4SURE LETTZ MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90