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SAN JOAQUIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA' IISION 1. % 6T WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY Qe, G f" SWEEPS LODE KESS �a /C TANK ID # - K SI2E Z00 000 1 FUEL TYPE [ FRFRAI SITF HISTORY III. TANK HISTORY Was Tank tested? Yes I CINO No Failed precision test 7 Yes Ref/Year No If yes, give dates) / / Was a repair made to the tank system? Yes N *" If yes, what was repaired? '0i-+< 4 permit current? Yes o Were soil samples analyzed? es Permit # - Facility Status Code PH- PH- DOC.SOiI/GW ContYes blvi Type of failure/discharge No nber of Tanks at facility 2 overfill Age of Tanks(if available) 7 Type of Tan Stee FbrgL SngL Dual III. TANK HISTORY Was Tank tested? Yes I CINO No Failed precision test 7 Yes Ref/Year No If yes, give dates) / / Was a repair made to the tank system? Yes N Yes If yes, what was repaired? '0i-+< 4 Was repair done under inspection? Yes o Were soil samples analyzed? es Dom No Pub BTX PH- PH- Pb/EDB blvi Type of failure/discharge et est long-term Leakage overfill unknown other:�+o.vmL ink C IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Afwa C Soil Samples Receiv Ye I CINO No Depth to Ground Water 6/' Ref/Year / x ; Average Annual Precipitation A=114 / / 10-25 On -Site Wells) Yes NAME OF EVALUATOR No Number & Type Irr Dom Pub I blvi S Score S Score S Seore�' 6sy Distance to Wells) from Tank �_ft; ft; ft C 10 pts C 9 pts C 5 s 0 R E if condition is met 0 R E if condition is met 0 R E i 28' ondit ion is met V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None C1 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 Neils, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one << COLUMN TOTALS>>>TOTAL POINTS + � + angle Result• ( RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts ' 40 pts or ass wlF-Fa;f-cxAlc sPi I-8 X0 sp I lro / MAXIMUM ALLOWABLE B -T -%-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. 1 NA\3 Sample Result: S 7y Ito'" GASOLI 1000 100 10 MAXIMUM ALLOWABLE TPN LEVELS (PPM) - 10,000 1000 100NE iPN DIESEL FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not rNVete 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). VII. 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 VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I CINO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 S I