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SAN JOAQUIN r�UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE"TH DIVISION I GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE PNAMEF FACiL1TY �� SWEEPS CODEj- r ve .�-- S ii a /.yL f!_2� TANKIDIZE ,, FUEL TYPE 11. GENERAL SITE HISTORY f , Is permit current? Yes No ermit # Facility Status Code Doc.Soil/GW Cont Yes No Number of Tanks at facility f' Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual 111, TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) Was a repair made to the tank system? Y..F No 71f yes, what was repaired? Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-01 17 EDB of failure/discharge catastrophic long-term leakage overfill unknown other: IV. REMCVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soii Samples Received Yes No Depth to Gro ursd Water s! Ref/Year Gl Average Annual Precipitation A= 14 10-25 On-Site Wells) Yes No Number & Type Irr Dom Pub --- S Score S Score S ficore Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C j 5 pts 0 if 0 if 0 if R condition R condition R ` condition V. Site Feature - Leaching Potential Analysis 3�() �/0 c/� E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet) fl C, >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 j Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxxLNonefi one one COLUMN TOTALS>>>TOTAL POINTS ) Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more x/41 - 48 pts 40 pts or less B TX E F B JT X E MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASQLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) TPH DIESEL 10,000 1000 100 FOOTNOTES: ***If documented soil and/or ground water contamination is present, don -til to 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 1f 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 f * r to Site Mitigation for Evaluation r �- 2. Recommend Site Closure Yes No If Yes, Refer g VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YE5 NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90