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SAN JOAOUIN•1''41`Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE/ 'DIVISION ow j, iT WORKSHEET FOR SITE CLOSURE EVALUATION - . DATE J� Z NAME OF FACILITY `,et., SWEEPS CODE ADDRESS OJ-P 9-77 TANK ID # - TANK SIZE FUEL TYPE Of 11. GENERAL SITE HISTORY *** Is permit current? Yes No Permit # - Facility Status Code Doc.Soit/GW Cont Yes Na 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 Fatted 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 Were soil sampLes analyzed? Yes No BTXE TPN-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 to Ground Water 1p Ret/Year Average Annual Precipitation A= 14 10-25 On-Site WeLL(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score Distance to Wells) 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 foothil Ls 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, rearby watts. At least More than xxxxxx None one one COLUMN TOTALS>>>TOTAL POINTS * f Sa is ResuLt• (B T X 0R E) v� RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less B T X E B T I X E �• �i MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 1000 100 10 S le MvQr'I T D MAXTPH LEVELS (PPM) DIESEL E 10,000 1000 100 444- FOOTNOTES: ***If documented soil and/or ground water contamination is es to the leaching potential analysis. (i.e., site is currently on UGT" taminatidn Liat for soil or gr ter.) \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 i 9/ 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No If Yes, Refer to to 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 YES1' 1jN01 DATE REFERRED / / DATE CLOSUILE LETTER 14AILED / / NAME OF EVALUATOR EH 23 60 (UGTWKSHT)\5/90