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SAN JOAQUIN COUiy.�JBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH ON I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 7 -LG S NAME OF FACILITY >V wGr..r ��GD VU�i SWEEPS CODE ADDRESS I 6V A� TANK ID # TANK SIZE Idr FUEL TYPE zpo� III. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes Ref/Year No If yes, give DATE REFERRED Was a repair made to the tank system? Yes No permit current? Yes Yes No No Permit # - Facility Status Code No Doc.Soil/GW Cont Yes TPH-G No mber of Tanks at facility Pb/EDB Age of Tanks(if avaiLable) Type of Tank Steel long-term Leakage Fbrgl Sngl Dual 1. III. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes Ref/Year No If yes, give DATE REFERRED Was a repair made to the tank system? Yes No If yes, what was repaired? Was repair done under inspection? Yes Irr No Data Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB Type of failure/discharge catastrophic long-term Leakage overfill unknown S C 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 -25 Ref/Year NO Average Annual Precipitation A=114 DATE REFERRED 10-25 On -Site Well(s) Yes No Number & Type Irr Data Pub S C Score 10 pts S C Score 9 pts S C Score 5 pts Distance to WeIL(S) from Tank ft; ft; ft 0 R E if condition is met 0 R E if condition is met 0 R E if condition is met V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) 2,1 >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration Cl of leachate (i.e., septic systems, water wells, ponds) None unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More then xxxxxx None one one J COLUMN TOTALS>>>TOTAL POINTS ' S leResuL �B T X OR E) = RANGE OF TOTAL POINTS 49 pts or more 41 - 48 40 pts or less 5• �.� B T X E B T X E K = N3e MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 I .3 .3 1. 1. NA\3 Sade Result: GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 .e,/, 090 TPH-6- f DIESEL 10,000 1000 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. TPM of 10 ppm (gasoline) or 100 ppm (diesel). \3 Levels for BTX&E are not applicable at a concentration _zs_ VI. STAFF RECOMMENDATION/CONCLUSION -r7/3 ! -7 —7,oV ,.f'�,vl 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No i 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation n 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 NAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90