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(NAME OF FACILITY S� ADDRESS TANK SIZE g FU 11. GENERAL SITE HISTORY ,Is permit current? FYes 'Number of Tanks at facility LII. TANK HISTORY SAN JOAQUIN 4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H�H DIVISION �,_¢ST WORKSHEET FOR SITE CLOSURE EVALUATION �-4 DATE 5— S SWEEPS CODE `r.(11 )/ J TANK ID # w f El TYPE (Ij,^ / f, Permit #I - IFacility Status Code I6�91-I OOa.SoiI/GW Cont IYesl IN r IAge of Tanks (if available) A?,, Type of Tank I Steel I I Fbrgl I Yj SngII Dual ',Was Tank tested? Yes X1 No Depth to Ground Water Failed precision test ? Yes No If yes, give date(s) 10-25 iWas a repair made to the tank system? Yes No No If yes, what was repaired? Number 8 Type was repair done under inspection?Yes Irr No Pub Were soil samples analyzed? Yes INo Score 9 pts if condition is met BTXE Scare 5 pts if condition is met TPH-G TPH-D Pb/EDB Minimum Depth to groundwater from the Soil Sample (feet) 90-1 5 -.� 5 •Fractures !Type of failure/discharge >100 catastrophic 51-100 long-term leakage 25-50\1 overfill I O unknown other: I`/. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) - Soil Samples Received Yes No Depth to Ground Water YES Ref/Year Average Annual Precipitation A= 14 10-25 IOn-Site WeLL(s) Yes NAME OF EVALUA70R No Number 8 Type Irr I Dam I Pub S C 0 R E Score 10 pts if condition is met S C O R E Score 9 pts if condition is met S C 0 R E Scare 5 pts if condition is met jOistance to Well frau Tank ft; ft; ft IV. Site Feature - Leaching Potential Analysis Minimum Depth to groundwater from the Soil Sample (feet) 90-1 5 -.� 5 •Fractures >100 51-100 25-50\1 in subsurface (applies to foothills or mountain areas) I O 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 welts, ponds) None Unknown Present :Unique site features: Recharge area, coarse soil, nearby welts. xxxxxx None At Least one More than one i COLUMN TOTALS>,>TOTAL POINTS I D * I " / �7 = 3 /J Sample Result: (B T X 0q E) ;'TaNKA7- All IUD RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts pts or les MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) B 1 T 50 X E 50 50 B .3 T .3 I X E 1. 1. NA\3 Sample Rerul�t:J,m1�NE itIV TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLI 1000 100 10 DIESEL 10,000 1000 100 'FOOTNOTES; ***If documented soil and/or ground water contamination is present, do not complete the le 'n tential r,K t1'e• analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) f1 i YJ�`r \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. hI� \2 If precipitation is > 40 inches, score 0 points. 1� \3 Levels for BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 Ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 E or TPN Concentrations > Allowable Levels I.YesNo 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation V:l. .REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR i Ie to be, c� ;,Mt, per, c cT�vtc`h � gasses Pts; S -3/ -DQ CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED DATE CLOSURE LETTER MAILED NAME OF EVALUA70R EH 23 80 (UGTWKSHT)\5/90