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® Y a SAN JOAQUIN C USLIC HEALTH SERVICES/ENVIRONMENTAL HEAL VISION I• _ WORKSHEET FOR SITE CLOSURE EVALUATION GATE NAME OF FACILITY SWEEPS CODE ADDRESS TANK ID # - TANK SIZEI FUEL TYPE II. GENERAL SITE HISTORY Is permit current? Yes !Number of Tanks at facility i;. TANK HISTORY M a Permit #- Facility Status Code Doc.SoiL/GW Cont Yes N Age of Tanks(if available) Type of Tank Stee[ Fbrgt Sngl Dual '.las Tank tested? Yes No Failed precision test ? Yes ll Ref/Year No I If yes, give dates) 14 `aas a repair made to the tank system? Yes No If yes, what was repaired? Was repair done under inspection? Yes Irr No Dom Were soil samples analyzed? Yes No BTXE Score 9 pts if condition is met TPH-G Score 5 pts if condition is mei TPH-D Pb/EDB 0 Type of failure/discharge i 'Minimum Depth to groundwater from the Soil Sample (feet)>100 catastrophic long-term leakage overfill Fractures in subsurface (applies to foothills or mountain areas) 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 Average Annual Precipitation A= 14 10-25 On -Site Wells) Yes No Number & Type Irr Dom Pub Score 10 `pts if condition is met S C 0 R E Score 9 pts if condition is met S C 0 R E Score 5 pts if condition is mei Distance to WeLI(s) from Tank S ft; ft; ft C 0 R V. Site Feature - Leaching Potential Analysis E '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 Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9. 10-25 xxxxxxx 26-40\2 lMan -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Wnique site features: Recharge area, coarse soil, nearby wells. 'r xxxxxx None At Least one More than one i COLUMN TOTALS>>>TOTAL POINTS + + _ Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more B T X E MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 41 - 48 pts 40 pts or less B TX .3 .3 11. E 1. NA\3 Sample Result: TPH GASOLINE MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 1000 100 10 10,000 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 O 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). VI. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No*If Yes, Refer to Site Mitigation for Evaluation /II. 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 DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EH 23 80 (UGTWKSHT)\5/90 W