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NAME OF FACILITY In SIZEI A00 11. GENERAL SITE HISTORY I SAN JOAQUIN CCWY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALI,IDIVISION UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE _ SWEEPS CODE �3 / !H w Permit current? Yes No Permit # - Facility Status Cade Doc.SOi L/GW Cmt YesF No ober of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dust Was Tank tested? Yes No No Failed precision test > Yes YES No If yes, give date(s) Average Annual Precipitation Was a repair made to the tank system? Yes No On -Site Well(s) If yes, what was repaired? Was repair done under inspection? Yes Number 8 Type No Irr Were soil samples analyzed? Yes No Pub BTXE S C 0 R E TPN -G S C 0 R E TPH-0 S C 0 R E Pb/ED8 Distance to WeLL(s) from Tank Type of faiLure/discharge catastrophic Minimum Depth to groundwater from the Soil Sample (feet) long-term Leakage 1,100 overfill 51-100 unknown I other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES No Depth to Ground Water YES Ret/Year NO Average Annual Precipitation A= 14 10-25 On -Site Well(s) Yes No Number 8 Type Irr Dom Pub S C 0 R E 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 WeLL(s) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) 1,100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None I Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 110-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic system, water wells, ponds) None 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 I E 50 R .3 T 3 X 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 mid/or ground water contaminstim is present, do not complete the Leaching potential acrolysis. (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 8TX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 E or TPN Concentrations > Allowable Levels -Yes No 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90