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SAN WOAOUIN jj PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT !VISION 1. WORKSHEET FOR SITE CLOSURE EVALUATION DATE NAME OF FACILITY SWEEPS CODE ;�3 '7 6 I ADORESS �L T �15� TANK ID 9 TANK SIZE FUEL TYPE I1. GENERAL SITE HISTORY Is permit current? Yes No Permit it - Facility Status Code Doc.Soil/OW Cont Yes 14 No Yes Humber of Tanks at facility Aga of Tanks(it available) Type of Tank Steel Irt Fbrgl Dom Sngl Dual III. TANK HISTORY Was Tank tested? Yes No Failed precision test 7 Yes Ref/Year No If yes, give date(s) 14 Was a reps it made to the tank system? Yes No if yes, what was repaired? Was repair done under fro tion? Yes Irt No Dom Were soil sauples analyted7 Yes No BTXE TPH•G TPH•0 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 Sanples Received Yes No Depth to Ground Water YES Ref/Year Average Annual Precipitation A• 14 10-25 On -Site WeIL(s) Yes No Nunber L Type Irt Dom Pub S C Score 10 pts S C Score 9 pts S C Score 5 pts Distance to WeLL(s) frac Tank ft; ft; ft 0 R E if condition is net 0 R E if condition is met 0 R E if condition is met V. Site Feature - Leaching Potential Analysis Minim Depth to groundwater from the Soil Sale (feet) >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present Average Arnual 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 walls, ponds) None UnknowntMors Unique site features: Recharge area, coarse soil, nearby wefts. At leastn xxxxxx None onee SPi as 1, = i7 P GC`s" ,— LUMN TOTALS»>TOTAL POINTS + + Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less sP3 ctwb -ND / yy� S •-/ Ci w!J NJ� MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) BT 1 50 X 50 E 50 8 .3 T .3 X 1. E 1. NA\3 Sample Result: GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) TPR DIESEL 10,000 1000 100 FOOTNOTES: "'If documented soil and/or ground water contamination is present, do not complete the leaching potential analysis. (i.e., site is currently on UST Contamination List for soil or ground water.) \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth u5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for BTX3E art not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). c VI. STAFF RECG0IENDAT ION/CONCLUSION Sf'I r R S 9 0 /°t�� (L ►Vi�(� 1. Are BTX b E or TPN Corcentrati ons > Allowable Levels 'Yea No �`��' L3 i �t° V itilT� e,1. _ 2. Recommend Site Closure Yes No If Yea, Refer to Site Mitigation for Evaluation ��3 �� J %� i1t/'13�'ai 1-34, f- rt3A = =s5o v n c .3 VII. REVIEW EVALUATION . TO BE COMPLETED aT A SUPERVISCR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER NAILED NAME CF EVALUATCR EH 23 80 (UCTWKSHT)\5/90 7_5h',� A ek `StOCA"cfz l{ * /✓ 7—