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SAN JOAQUIN�TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL No DIVISION 1. GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY SWEEPS CODE ADDRESS TANK ID # - TANK SIZE FUEL TYPE 11. GENERAL SITE HISTORY *** Is permit current? Yes - No Permit # - Facility Status Code Doc.Soi L/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 7 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/EDB Type of failure/discharge catastrophic long-term leakage overfill unknown other: !V. 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 TconditinR Score Distance to WeLI(s) from Tank ft; ft; ft C 10 p[s C 5 pis 0 if 0 if R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met Minimum Depth to groundwater from the Soil Sample (feet) >100 Cl 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Oj 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) None Unknown S Present Unique site features: Recharge area, coarse soil, nearby wells. R At qteast More than xxxxxx None "�/� one COLUMN TOTALS>»TOTAL POINTS 6 + 'L .j Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more / 41 - 48 pts .740 pts or Less B T X E B T 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 MAXIMUM ALLOWABLE TPH LEVELS (PPM) J' m TPH D DIESEL 10,000 1000 100 FOOTNOTES: ***If documented soil and/or ground water contamination is present, do n ete 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). . STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation Zr Evaluation 1. 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 --