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SAN JOAQUIN ' PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE 441VISION 1. -.. r WORKSHEET FOR SITE CLOSURE EVALUATION M� DATE a NAME OF FACILITYha( r SWEEPS CODE 4 3a 3 �'9 ADDRESS 3 TANK ID # q-Aa 3Y? TANK SIZE 3 Do U IFUEL TYPE j_e 11. GENERAL SITE HISTORY Is permit current? Yes No Permit # - Facility Status Cade DOC.SOi L/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel FbrgL Sngl Dual 13 1 III. TANK HISTORY Was Tank tested? Yes XN0 Failed precision test ? 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 Na BTXE TPH-G TPN-D Pb/EDB Type of failure/discharge catastrophic long-tern 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 56 Ref/Year 36 Average Annual Precipitation A= 14 10-25 On-Site Well(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score Distance to WelL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts O if O if O if R condition R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet),)6— >100 51-100 25-50\1 Fractures in subsurface CappLies to foothills or mountain areas) J O 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 Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. I At Least More than xxxxxx None y ane one COLUMN TOTALS»,TOTAL POINTS 1 6 + � I + Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less -pW = ND MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 9 50 50 50 .3 .3 1. E. NA\3 Sample Result: GASOLINE 1000 100 10 /- Q TPH )] MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 FOOTNOTES: `'**If documented soil and/or ground water contamination is present, eaching 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 sIX1 � .L Dresz4e D1* vr� y1 P Ft 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No � 1. 'o 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation far Evaluation R -'1 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 V NOI DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR I UL EH 23 80 (UGTWKSHT)\5/90