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IP ,_ SAN JOAQUIN k,__4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HF-Aa�IVISION I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE/L�/G�' INANE OF FACILITY I I SWEEPS CODE NK SIZEI 555 64 CENERGI SITE HISTORY TYPE TANK ID 111. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes Ref/Year No If yes, give date(s) / / Was a repair made to the tank system? Yes No EVALUATOR permit current? Yes Yes No Permit # - Facility Status Code DOc.SoiL/GW Score 10 pts if condition is met Cont Yes TPH-G No tuber of Tanks at fac lity Pb/EDB 1 Age of Tanks(if available) Type of Tank Steel long-term Leakage Fbrgl Sngll Dual unknown 111. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes Ref/Year No If yes, give date(s) / / Was a repair made to the tank system? Yes No EVALUATOR If yes, what was repaired? Was repair done order inspection? Yes Irr No Dam Were soil samples analyzed? Yes No Score 10 pts if condition is met BTXE Score 9 pts if condition is met TPH-G Score 5 pts if condition is wet TPN -D ft; ft; ft Pb/EDB V. Site Feature - Leaching Potential Analysis Type of failure/discharge catastrophic long-term Leakage overfill Fractures in subsurface (applies to foothills or mountain areas) unknown None other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES No Depth to Ground Water D Ref/Year DATE REFERRED Average Annual Precipitation A-114 / / 10-25 on -Site WeIL(s) Yes EVALUATOR No Number & Type Irr Dam Pub S C 0 R E Score 10 pts if condition is met S C 0 R E Score 9 pts if condition is met S C 0 R E Score 5 pts if condition is wet Distance to WeLL(s) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Semple (feet) S� >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 of leachate (i.e., septic systems, water wells, ponds) None 11 Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. XXXXX, None At Least one More than one COLUMN TOTALS>>>TOTAL POINTS + 2 (� + Sample Result: IS T X OR E) RANGE OF TOTAL POINTS g _p.n;.D 4A"O-.-710&-1 +t' O'LL fPjl Yr` Id,+CjgO✓N MAXIMUM ALLOWABLE S -T -X -E LEVELS (PPM) 49 pts or more 0-"s 40 pts or Less B 1 T 50 X 50 E 50 B T X .3 .3 1. E 1. NA\3 Semple ppesult: N•� )1pOPP'�n9a 0_2PN GASOLINE D MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 1000 100 10 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 UST 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 esel). VI. STAFF RECOMMENDATION/CONCLUSION D (V=7NN'''°�" Yevom_— %PT 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No /"^ 2. Recommend Site Ctosure Yes No If Yes, Refer to Site Mitigation for Evaluation TGgc IF- ) VII. REVIEW EVALUATION - TO BE COMPLETED Y A SUPERVISOR/SENIOR T j Z1 t44— ILi�ae D s 9!'' CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATI17777] DATE REFERRED / / DATE CLOSURE LETTER MAILED / / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 Rob