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SAN JOAQUIN�TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL No DIVISION I' GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE \ NAME OF FACILITYLllrAia�O SWEEPS CODE ADDRESS TANK ID TANK SIZE �j'� FUEL TYPE W'p 11. GENERAL SITE HISTORY Is permit current? Yes No Permit 0 - *** Facility Status Code Doc.Soi l/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available \Gr- \ Type of Tank Steel dlrbrgL Sngt Dual 111. 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 Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB Type of fai Lure/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 ` Ref Year\ \cAverage Annual Precipitation A= 14 10-25 On-Site WeLL(s) Yes No Number & Type Irr Dan Pub Distance to Wells) from Tank ftp S Score S Score S Score 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 q 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 O� Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least q More than xxxxxx None one one COLUMN TOTALS»>TOTAL POINTS + 3\p + - Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less !�D 8 T X E 8 T X E MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. E NA\3 Sample RR.essuyl,tt:� �� _ _ GASOLINE 1000 100 10 9W�^�R<a• MAXIMUM ALLOWABLE TPH LEVELS (PPM) \O Vo kp TPH IESEL 10,000 1 1000 100 FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No / 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR,,WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTE NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 --