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SAN JOAQUIN CLIC HEALTH SERVICES/ENVIRONMENTAL HEAL ION I w KSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY SWEEPS CODE ADDRESS D V1 ' TANK ID # - TANK SIZE FUEL TYPE 1;C Lj I1. GENERAL SITE HISTORY xrr Is permit current? Yes No Permit 9 - Facility Status Code Doc.Soil/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 ? Yes No If yes, give date(s) Was a repair made to the tank system? Yes I 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: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) SoiL Samples Received Yes No Depth to Ground Water ef/Yearlill w3lAverage Annual Precipitation A=114 10-25 On-Site WeLL(s) Yes No Number 8 Type Irr Dom Pub S Score S Score S Scare Distance to YeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts 0 if 0 if 0 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) >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 10-351xxxxxxx 26-40\2 Man-Made conduits which increase vertical migration rjjof Leachate (i.e., septic systems, water wells, ponds) None Un n Present Unique site features: Recharge area, coarse soil, nearby wells. t Le s More than xxxxxx None one COLUMN TOTALS>>>TOTAL POINTS * _ ST7 . le Reesu� (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less Vora V?- BT X E B T X E �y_,T4 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) 53 42(y) TPH d DIESEL 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 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). V1. 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 Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED Bf 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