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SAN JOAQUIN _ .TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE I DIVISION I. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY SWEEPS CODE ADDRESS ev� TANK ID # - TANK SIZE11 I FUEL TYPE f ll. GENERAL SITE HIS ORY *** Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl , Dual III. TANK HISTORY Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) Was a repair made to the tank system? Yes No If yes, what was repaired? Was repair done under inspection? Yes No HWere soil samples analyzed? Yes Na BTXE TPH-G TPH-D Pb/EDB Type of failure/discharge catastrophic long-term Leakage overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yes No Depth toGround Water 2b Ref/Year Average Annual Precipitation A=114 .10-25 On-Site Wett(s) Yes No Number & Type Irr Dan Pub S Scare S Score 5 Score Distance to Weil(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts 0 if 0 if 0 if R condition R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met 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 welts, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At Least More than xxxxxx None one one COLUMN TOTALS>>>TOTAL POINTS + D = 34:. Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less �` lam+^f•1 B T % E B T % E °O �� N MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 \.O^N D T") MAXIMUM ALLOWABLE TPH LEVELS (PPM) 1.0..141) TPI DIESEL 10,000 1000 100 FOOTNOTES: K1***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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Concentrations > Atlowable Levels *Yes No 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YESI NO DATE REFERRED / / DATE CLOSURE LETTER Ml12 LED / / NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90