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SAN JOAQUIN * PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAIWIVISION I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE CJ !NAME OF FACIL17Y �� SWEEPS CODE !ADDRESS 4� �} f��Nc-R�' TANK 3D # o� TANK SIZE ] FUEL TYPE V)`U_jaL II. GENERAL SITE HISTORY *** :Is permit current? Yes No Permit 9 Facility Status Code Dac.Soil/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel FbrgL SngL Dual III. 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-D Pb/E0B ;Type of failure/discharge catastrophic long-term leakage overfill unknown other: iV. REMOVAL HISTORY (ATTACH INSCTION 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) YesL I No Number & Type Irr Dom 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 O 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 51-101 25-50\1 iFractures in subsurface (applies to foothills or mountain areas) None t--\ Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\Z .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 i 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 1 T � X � E9 JT � XE MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B1 50 50 50 .3 .3 1.1 1. I NA\3 Sample Result: GASOLINE 1000 100 10 f MAXIMUM ALLOWABLE TPH LEVELS (PPM) TPH DIESEL 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 No 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation V'1. REVIEW EVALUATION - TO SE 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 SETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90