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SAN JOAQUIN 0UNTY ENVIRONMENTAL HEOPTH DEPARTMENT <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION <br />It <br />SITEIFACILITYNAME: I P�GGISP.1 c�aw1� (',i1n n I�tAnh. STATUS CODE: <br />ADDRESS: <br />TANK SIZE:, j .`_A o1 `q 0(� I FUELTYPE: I �$ �j 0orjj , A <br />II. GENERAL SITE HISTORY <br />Is Permit Current? x Yes ❑ No Documented Soil/GW Contamination?"* <br />Number of Tanks at Facility3 Age of Tanks (if available) Type of Tank <br />ual <br />III. TANK HISTORY <br />Was Tank Tested? 53 Yes O No Failed Testing? ❑ Yes 3 No If Yes, Provide Dates: <br />Was Tank System Repaired? ❑ Yes ® No If Yes, Describe Repair: <br />Was Repair Done Under Permit? ❑ Yes ❑ No Were Soil Samples Analyzed? A Yes ❑ No ® BTEXEDB ®TPH-G 11TPH-D <br />� ®OTHE D <br />Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill Id Unknown ❑ Other <br />IV RPMnVAI 141AMRV /Af1e�6 Doer <br />Soil Samples Received? x Yes ❑ No <br />Seasonal High Depth to GW Xft bgs <br />Year/ Reference <br />/9V3 <br />Onsite and/or Nearby Well(s)? ❑ Yes t,$,No <br />C <br />Score 10 <br />C <br />Score 9 <br />S <br />❑ Irrigation: # Distance to Tank _ ft <br />L] Domestic: # Distance to Tank _ ft <br />C <br />points if <br />O <br />points if <br />C <br />Score 5 points if <br />L3 Public: # Distance to Tank _ ft <br />R <br />E <br />condition is <br />met <br />R <br />E <br />condition is <br />met <br />O <br />R <br />E <br />condition is met <br />V. SITE FEATURE – LEACHING POTENTIAL ANALYSIS <br />Minimum Depth to Groundwater from Soil Sample Depth (feet)" <br />>100 <br />51-100 <br />Q <br />26-501 <br />Fractures in Subsurface (applies to foothill or mountain areas) <br />0 <br />None <br />Average Annual Precipitation (14 inches for SJC area) <br />-- <br /><10 <br />9 <br />10-25 <br />—rMore <br />402 <br />Man -Made Conduits which Increase Vertical Migration <br />i.e. septic sstems, water wells, ponds)--"' <br />None <br />Unknown <br />ent <br />Unique Site Features: Recharge Area, Coarse Soil (coarse sands, <br />gravels), nearby wells <br />None <br />l <br />At Least One <br />an One <br />Column Totals Total Points <br />p <br />a7 <br />® 1 <br />= 3-7 <br />Sample Results for BTEX: <br />Range of Total Points <br />49 Points or More <br />41 – 48 Points <br />40 Points or Less <br />< 0.075 <br />Maximum Allowable BTEX <br />B <br />T <br />E <br />X <br />—13—FT <br />E <br />X <br />Levels m <br />1.0 <br />50 <br />50 <br />50 <br />0.3 <br />10.3 <br />1 1.0 <br />1.0 <br />N/A3 <br />Sample Results for TPH: <br />19P6 n i '1 <br />Wximum <br />Allowable TPH <br />Gasoline <br />1,000 <br />100 <br />10 <br />n 706s0 <br />Levels m <br />Diesel <br />10,000 <br />1,000 <br />100 <br />Footnotes: "*If documented soil and/or groundwater contamination is present, do not complete leaching potential analysis (i.e. site is already on the contamination list). <br />t If depth is >5 feet and <25 feet, score 0 points. If depth is <=5 feet, do not use table. 2 I precipitation is > 40 inches, score 0 points. <br />3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH-Gasoline or 100 ppm for TPH-Diesel. <br />VI. STAFF RECOMMENDATION/ REFERRAL/ REVIEW <br />1. Are BTEX or TPH Concentrations > Allowable Levels? XYes ❑ No <br />2. If No, Is Site Closure Recommended? ❑ Yes ❑ No <br />Completed By: M VAI moi. <br />Date Referred to Site Mitigation Unit for Final Actions 31 <br />0q <br />Reviewed By: <br />Concur with Staff Recommendation ❑ Yes ❑ No <br />Date Closure Letter Mailed <br />tAll Cases are Referred to Site Mitigation for Final Action <br />*Subtract soil sample depth from amundwater denth to deteonine dl<r n>.„a,..,.,,,,,n.,,,e. <br />EH 23-0080 (Rev6/4/2007) <br />