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SAN JOAQUII )NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL rH DIVISION I. 1GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY7 ` - _- " -y— SWEEPS CODE ADDRESS / L /�� 'C TAN, ID # 3 TANK SIZEJU, ,,, r FUEL TYPEP..CA_.e co *** > permit current? Yes No Permit # Facility Status Code C) I Doc.SoiL/GW Cont Yes No tuber of Tanks at facility Age of Tanks(if available) i Type of Tank Steel KFbrgL Sngl Dual TANK HISTORY ` Was Tank tested? Yes No Depth to Ground Water�, No Failed precision test ? Yes No If yes, give date(s) 14 Was a repair made to the tank system? Yes No If yes, what was repaired? Number & Type Was repair done under inspection? Yes Dom No Pub Were soil samples analyzed? Yes No S C 0 R E BTXE S C 0 R E TPH-G Distance to WeLL(S) from Tank TPH-D Pb/EDB Minimum Depth to groundwater from the Soil Sample (feet) Type of failure/discharge >100 catastrophic 51-100 long-term leakage 25-50\1 overfill unknown None 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�, Ref/Year • Average Annual Precipitation A= 14 10-25 On -Site WeLL(s) Yes No Number & Type Irr Dom 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 met Distance to WeLL(S) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 �l 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) x 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) x None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None At least one More than one COLUMN TOTALS» >TOTAL POINTS -X L' + y _, Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or Less MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) B 1 T 50 X 50 E 50 B .3 T .3 X 1. E 1. NA\3 Sample Result: TPH GASOLINE MAXIMUM ALLOWABLE TPH 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 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 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No F*If Yes, Refer to Site Mitigation for Evaluation 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 NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90