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SAN JOAQUIN C` Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL ✓)[VISION GATE S r / I EWT WORKSHEET FOR SITE CLOSURE EVALUATION NAME OF FACILITY old- SWEEPS CODE ADDRESS S�G' TANK [D @ TANK SI2E /01&" FUEL TYPE D �� II. GENERAL SITE HISTORY rer Is permit current? Yes No Permit it - Facility Status Code I I? Doe.SOiL/GW Cont Yes IXNo Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel FbrgL SngL Dual 19 III. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes Ret/Year No If yes, give date(s) 14 Was a repair made to the tank system? Yes No If yes, what was repaired? Was repair done under inspection? Yes M01 Were soil samples analyzed? Yes Pub No Score 10 pts if condition is met BTXE Score 9 pts if condition is met TPH-G Score 5 pts if condition is met TPH-D ft; ft; ft Pb/EDB Type of Failure/discharge Minimum Depth to groundwater from the Soil Sample (feet) catastrophic >100 long-term Leakage 51-100 overfill 25-50\1 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 YES Ret/Year NO Average Annual Precipitation An 14 10-25 On -Site WeIL(s) Yes No Number & Type Irr Dam Pub S C 0 R E Score 10 pts if condition is met 5 C 0 R E Score 9 pts if condition is met 5 C 0 R E Score 5 pts if condition is met Distance to Wells) frac Tank ft; ft; ft 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 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 Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None At Least one More than one COLUMN TOTALS>>>TOTAL POINTS + + 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) BT 1 50 X 50 E 50 B .3 T .3 X 1. E 1. MA\3 Sample Result: TPH GASOLINE MAXIMUMALLOWABLE TPN LEVELS (PPM) DIESEL 1000 10,000 100 7000 10 100 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., scare 0 points. If depth c5 ft., do not use table. \2 If precipitation is > 40 inches, scare 0 points. \3 Levels for STX&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 If Yes, Refer to Site Mitigation for VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALOATION YES NO DATE REFERRED / / DATE CLOSURE LETTER NAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90