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SAN JOAQUIN COWITT PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALrI OdDATEj l I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION NAME Of FACILITY 7 :l ADDRESS v /- / EZ] TANK SIZE 550 IFUEL TYPE Ii. GENERAL SITE HISTORY •ter Is permit current7 Yes No Permit # - Facility Status Code Doc.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 LA, Failed precision test 7 Yes No If yes, give date(s) Was a repair made to the tank system? Yes No If yes, what was repaired7 was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D 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= 14 10-25 On-Site Wells) Yes No Number 8 Type Irr Dom Pub S Score S Score S Score Distance to wells) frau Tank ft; ft; ft C 10 pts C 9 pts C 5 pts 0 if 0 if 0 if R condition R condition R condition V. Site Feature - Leaching Potential Analysis 4/"0 E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet)/f19 — >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) U None Unknown Present Average Annual Precipitation (inches) 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) r (� more Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one c-, COLUMN TOTALS>>>TOTAL POINTS A 1) • I 9 * .J �.. Sample Result: IS T X OR E) RANGE Of TOTAL POINTS 49 pts or more 41- 48,-ptg 40 pts or less L L, N D B TX E BT X E MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 �:3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 N � _TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 100 100 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF 3ECCMMENDAT ION/CONCLUSION 1. Are BTX 8 E or TPH Concentrations > Allowable Levels -Yes Nc 2. Recamiend Site Closure Yes No If Yes, Refer to Site Mitigation far 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 YES 0 DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90