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SAN JOAOUIN-C^ PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL7—)IVISION 1. v WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY �` jJ SWEEPS COOP ADDRESS / l� a �ry,y` TANK ID # TANK SIZE /UUP FUEL TYPE II. GENERAL SITE HISTORY Is permit current? Yes No Permit # Facility Status Code r,3 Doc.Soi[/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel rgl Sngl Dual Ill. TANK HISTORY _ Was Tank tested? Yes 71No failed precision test ? Yes No If yes, give date(s I I I I I E, i 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 No BTXE TPH-G TPH-D Ph/EBB Type of failure/discharge catastrophic long-term leakage overfill unknown other: 1 IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes No Depth to Ground water V,<) R, it Precipitation A-114 10-25 On-Site Weil(s) Yes No Number & Type Irr Doto �' ore S Score 1v Distance to wetl(s) from Tank ft; ft; f pts C 5 pts �f O !if ondition R condition V. Site Feature - teaching Potential Analysis s met E is met Minimum Depth to groundwater from the Snit Sample (feet) !l© 1-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) Unknown Present Average Annual Precipitation (inches) xxxxxx <1O 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. At least More than xxxNone one one xxx COLUMN TOTALS>»TOTAL POINTS > ; : i Sample Result: CB T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less 81 T I x E B T X E MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11501 50 50 .3 .3 1.1 1. NA\3 Sample Result: GASOLINE 1000 100 10 MAXIML14 ALLOWABLE TPH LEVELS (PPR) TAH DIESEL 10,000 1000 100 FOOTNOTES: mIf documented soil and/or ground water contamination is present, do not complete the teaching potential analysis. (i.e., site is currently on UGT Contamination List for sail or ground water.) \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth <4 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 (dieset). 1 VI. STAFF RECOMMENDATION/CONCLUSION - w' _3 r— W 1. Are BTX & E or TPH Concentrations > ALL to Levels 'Yes No VO 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation Vll. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR l CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES HO REFERRED TO SITE MITIGATION FOR EVALUATION TES Nd i i DATE REFERRED / / DATE CLOSURE LETTER MAILED / / I r i NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 1 ..1