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i permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No tuber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual 111. TANK HISTORY Was Tank tested? Yes No SAN JOAQUIN 0 PUBLIC HEALTH SERVICES/ENVIRONMENTAL H40 "" " I• yes, give date(s) uuST WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY NAME OF EVALUATOR li �"' _ .,I Was repair done under inspection? Yes SWEEPS CODE n Dom Were soil samples analyzed? Yes No BTXE ADDRESS L) TPN -D Pb/EDB TANK ID # TANK SIZE FUEL TYPE long-term leakage / 11. GENERAL SITE HISTORY unknown S other: S i permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No tuber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual 111. TANK HISTORY Was Tank tested? Yes No Failed precision test 7 Yes Ref/Year No If yes, give date(s) / / Was a repair made to the tank system? Yes No NAME OF EVALUATOR If yes, what was repaired? Was repair done under inspection? Yes Irr No Dom Were soil samples analyzed? Yes No BTXE TPH-G TPN -D Pb/EDB Type of failure/discharge catastrophic long-term leakage overfill unknown S other: IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Sail Samples Received Yes No Depth to Ground Water YES Ref/Year ; Average Annual Precipitation A-114 / / 10-25 On -Site WeIL(s) Yes NAME OF EVALUATOR No Number 6 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 R If condition 0 R if condition 0 R if condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met Minimum Depth to groundwater frac the Soil Sanple (feet) >100 51-100 25-50\1 Fractures In subsurface (applies to foothills or mountain areas) None Unknown Present Average Arcual Precipitation (inches) I 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) Nora Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one H'I k)3.S ' :. VJ COLUId TOTALS>>>TOTAL POINTS s a a Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pis 40 pts or less s> P Lf4% ) _ NAXbRUM ALLOWABLE B -T -X -E LEVELS (PPM) B 1 T 50 X 50 E 50 B .3 T .3 X 1. E 1. MA\3 Sample Result:GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) 10,000 1000 100 TPH DIESEL FOOTNOTES: " if documented soil and/or grand 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 STXSE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). Vt. STAFF REC"ENDATION/CONCLUSION o'exg4Yf'i� 6,", P13 = �✓•j� p///��,,,�� 1. Are BTX 3 E or TPN Concentrations > Allowable Levels 'Yes No .�� oAJb� J� _ 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 RECCMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER NAILED NAME OF EVALUATOR EH Z3 80 (UGTWKSHT)\5/90 T -?9 (` k,,5 L, F) d,,,L 4Ez lfl-rd E