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BLIC SAN UOAOUIN CabNfT WORKSHEET SETEICES1611 EVALUATION HEAL"eDIVISION NAME OF FACILITY DATE ADDRESS c.; SWEEPS CODE a TANK ID # 2 Gi - TANK SIZE Aj&OD FUEL TYPE II. GENERAL SITE HISTORY Is permit current? Yes No Number of Tanks at facility III. TANK HISTORY ' Facility Status Co Age of Tanks(if available) Type of Soil/GW Cont Oust Was Tank tested? Yes No No Failed precision test ? Yes NO No If yes, give date(s) A=114 Was a repair made to the tank syste? Yes No Yes If yes, what was repaired? No Was repair done under inspection? Yes No Were soil samples analyzed? Yes Pub No S C 0 R E BTXE S C 0 R E TPN -G S C 0 R E TPH-D Pb/ED8 ft; ft; ft Type of failure/discharge V. Site Feature - Leaching Potential Analysis catastrophic Lorhg-term leakage overfill unknown Fractures in subsurface (applies to foothills or mountain areas) other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA Fent LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes YES No REFERRED TO SITE MITIGATION FOR EVALUATION Depth to Ground Water NO Ref/Year Average Amual Precipitation A=114 DATE CLOSURE LETTER NAILED 10-25 On -Site Well(s) Yes No Number & Type Irr Dam 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 pis 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 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None I Unknown Present Average Annual Precipitation (inches) xxxxm <10 9 110-25 x, xxxx 26-40\2 Man -Made conduits which increase vertical migration of Leachate (i.e., septic systems, water wells, pads) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxx:at None At least one More than one COLUMN TOTALS»>TOTAL POINTS Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 pts or less MAXIMA( ALLOWABLE B -T -X -E LEVELS (PPM) B 1 TX 50 50 E 50 B .3 T X E .3 1. 1. NA\3 Sample Result: TPH GASOLINE MAXIMA( ALLOWABLE TPN LEVELS (PPM) DIESEL 1000 100 10 10,000 1000 100 FOOTNOTES: If doc aerated 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (dieset). 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 8Y A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED DATE CLOSURE LETTER NAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90