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I. R FACILITY `� `� �— E � �y� T fl. GENERAL SITE HISTORY is permit current? Yes Number of Tanks at faciL 111. TANK HISTORY SAN JOAQUIN CL PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL 'IVISION RST WORKSHEET FOR SITE CLOSURE EVALUATION _JDATE 11 SWEEPS CODE �'7 / C3OCOp - IL e-, " . G� TANK ID # FUEL TYPE1 IO Permit 41 - '** Facility Status Cade Dac-Soil/GW Cont Yes N �'7 Age of Tanks(if available) <7,)— Type of Tank Steel Fbrgl Sngl Dual >In Was Tank tested? Yes iX1 No YESI Failed precision test Yes No If yes, give dates) / / / / Was a repair made to the tank system? Yes No Yes If yes, what was repaired? Was repair done under inspection? Yesl No Were soil samples analyzed? Yes Dom No Pub XE Score 10 pts if condition is met TPH -G Score 9 pts if condition is met TPH-D Score 5 pts if condition is met Pb/EDB ft; ft; ft Type of fai Lure/discharge V. Site Feature - Leaching Potential Analysis catastrophic Long-term leakage overfill 51-100 _JT unknown 25-50\1 other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes NO No YESI Depth to Ground Water Ret/Year DATE REFERRED Average Annual Precipitation A=114 10-25 On -Site WeLL(s) Yes No Number 8 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 Wells) from Tank ft; ft; ft V. Site Feature - Leaching Potential Analysis Mini" 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 zxxxxxx 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 Least one More than one COLUMN TOTALS»>TOTAL POINTS I + + _ 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 8 .3 T X .3 1. E I. NA\3 Sample Result: TPH GASOLINE MAXIMUM ALLOWABLE TPN 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 BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). V1. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 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 70 SITE MITIGATION FOR EVALOATION YESI NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90