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SAN JOACUIN COUN ELIC HEALTH SERVICES/ENVIRONMENTAL HEALTH SIGN I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE r•.. �1 ' NAME OF FACILITY SWEEPS CODE / V ADORESS'37igiTANK ID # - I 6 TANK SIZE FUEL TYPE E p it. GENERAL SITE HISTORY *** s permit current? Yes No Permit # - Facility Status Code Doc.Soit/GW Cont Yes No umber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgt Sngl Duct all. 1—ft naaj%ml Was Tank tested? EEI No I Failed precision test ? Yes Ref/Year No If yes, give date(s) 14_110-25 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 sail samples analyzed? Yes S No S C 0 R E STXE S C 0 R E TPN -G Distance to Wells) from Tank TPH-D R Pb/EDB Minimum Depth to groundwater from the Soil Sample (feet) Type of failure/discharge catastrophic long-term Leakage Fractures in subsurface (applies to foothills or mountain areas) overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES No YES Depth to Ground Water Ref/Year ; Average Annuat.Precipitation A= 14_110-25 On -Site WeLL(s) Yes No Number & Type Irr Dom Pub S 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 Wells) from Tank ft; ft; ft C 0 R V. Site Feature - Leaching Potential Analysis E 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 Unknown Present Average Annual Precipitation (inches) I 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 welts. xxxxxx None At least one More than ane COLUMN TOTALS>» TOTAL POINTS + + _ Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less B T MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 X 50 E 50 B .3 JT .3 X E 1. 1. NA\3 Sample Result: TPN 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 teaching potential analysis. (i.e., site is currently on UGT Contamination List for snit 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 BTX&E are not applicable at a TPH 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 No If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR 'WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERM TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90