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SAN JOAQUIN OQY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEODIVISION I. T WORKSHEET FOR SITE CLOSURE EVALUATION NAME OF FACILITY DATE SWEEPS CODE ADDRESS TANK ID it TANK SIZE FUEL TYPE 11. GENERAL SITE HISTORY Is permit current? Yes No Permit i< - *** Facility Status Code Doc.Soil/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) T ype of Tank Steel Fbrgl Sngl Dual I11. TANK HISTORY Was Tank tested? Yes No Failed precision test 7 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 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 Ret/Year Average Annual Precipitation A= 14 10-25 On-Site Wetl(s) Yes No Number 8 Type Irr Dom Pub Distance to WeII(S) from Tankft; ftS Score S Score S Score ; ft C 10 pts C 9 pts C 5is 0 it 0 if 0 if P V. Site Feature - Leaching Potential Analysis R condition R condition R condition E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 s 25.50\1 Fractures in subsurface (applies to foothills or mountain areas) C) 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, nearby wells. At Least More than xxxxxx None r/ one one COLUMN TOTALS»>TOTAL POINTS + Y 7 Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1B 50 50 50 .3 .3 1. 1. NA\3 Sample Result: - _ GASOLINE 1000 10p -- MAXIMUM ALLOWABLE TPH LEVELS (PPM) 10 TPH DIESEL 10,000 1000 100 .FOOTNOTES: ***If documented soil and/or ground water contamination isresent, do n ! the analysis. (i.e., site is currently on UGT Contamination List for soil or ground ewater.)aching �tential \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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 8 E or TPH 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 NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO HOF / / DATE CLOSURE LETTER MAILED �� EH 23 80 (UGTWKSHT)\5/90 - _.