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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HIW DIVISION I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE ®® NAME OF FACILITY F. WPM SWEEPS CODE ADDRESS C��® TANK ID TANK SIZE Y� at7C?l7 c"1 FUEL TYPE II. GENERAL SITE HISTORY *..* s permit current? Yes No Permit # - Facility Status Code Doc.SoiI/GW Cont Yes No umber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual III. TANK HISTORY Was Tank tested? Yes YESNO No Failed precision test ? Yes Average Annual Precipitation No If yes, give date(s) on -Site Wells) Was a repair made to the tank system? Yes Noi DATE CLOSURE LETTER MAILED If yes, what was repaired? Was repair done under inspection? Yes Dan No7 Pub Were soil samples analyzed? Yes No BTXE TPH-G TPH-01 Pb/EDB Type of failure/discharge catastrophic long-term leakage overfill S unknown S C other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes No YESNO Depth to Ground Water Ref/Year REFERRED TO SITE MITIGATION FOR EVALUATION Average Annual Precipitation A= 14 10-25 on -Site Wells) Yes / / No DATE CLOSURE LETTER MAILED Number & Type Irr Dan Pub S Score 10 pts S C Score 9 pts S C Score 5 pts Distance to Wells) from Tank ft; ft; ft C 0 if condition is met 0 R E if condition is met 0 R E if condition is met R V. Site Feature - Leaching Potential Analysis E Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 5 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None CkUnknown 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) ®® None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None a one one COLUMN TOTALS»>TOTAL POINTS %IV - + J = y.�\- Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less B T X E B T X E �9 MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 L®� MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 PH 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. \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 VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR I CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESNO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR A i o EH 23 80 (UGTWKSHT)\5/90