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1' SAN lOAOUIN CdblIffY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALI�DIVISION No Permit X UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE tea_ HANE OF FACILITY Code Average Annual Precipitation S SWEEPS CODE ADDRESS Yes No C c.�9,� v v r� TANK ID X O SCJ D_3 TANK SIZE D FUEL TYPE �' Age of Tanks(if available) II. GENERAL SIT HISTORY of Tank Steel Na Is permit current? Yes NO No Permit X - Facility Status Code Average Annual Precipitation If yes, give date(s) Ooc.Soil/GW Cant .+r Yes Yes No No Number of Tanks at facility Was repair done under inspection? Yes Age of Tanks(if available) Type of Tank Steel Na Fbrgl BTXE Sngl Dual ft; ft; ft III. TANK HISTORY V. Site Feature - Leaching Potential Analysis catastrophic long-term leakage overfill Was Tank tested? Yes NO No YESNO Failed precision test ?IYes F No Average Annual Precipitation If yes, give date(s) 14 Was a repair made to the tank system? Yes No No If yes, what was repaired? Was repair done under inspection? Yes No Were soil samples analyzed? Yes Score5 10 pts if condition is met Na Score 9 pts if condition is met BTXE Score 5 pts if condition is met TPH-G TPH-01 Pb/ED8 ft; ft; ft Type of failure/discharge V. Site Feature - Leaching Potential Analysis catastrophic long-term leakage overfill 51-100 unknown 25-50\1 other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received I Yes YES NO No YESNO Depth to Ground Water Ref/Year DATE REFERRED Average Annual Precipitation A= 14 10-25 On -Site Wells) Yes No Number & Type Irr Dam Pub S C 0 R E Score5 10 pts if condition is met 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 V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 I 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None ( Unknown Present Average Annual Precipitation (inches) xxxxxxl <10 9 110-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None I Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None At least one More than one 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 MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) B 1 T 50 X 50 E 50 B T X .3 .3 1. E 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 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 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 INOT7 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 REFERRED TO SITE MITIGATION FOR EVALUATION YESNO DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90