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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITY/TANK INFORMATION DATE: 1 4-29-16 SITE/FACILITY NAME: I Mary Tsutaoka Residence STATUS CODE: I LEA code 09 ADDRESS: 1833 W. Kettleman Ln. Lodi,CA 95241-0373 CITY: I Lodi FA#: FA0023349 PR#: PR0540845 I TANK#j 39-0520796 TANK SIZE: 550 gallons FUEL TYPE: -ne%L IL GENERAL SITE HISTORY Is Permit Current? ❑ Yes ❑ No 0 n/a Documented Soil/GW Contamination?``** ❑ Yes IRI No Number of Tanks at Facility 2 Age of Tanks(if available) unknown Type of Tank EISteel ❑Fiberglass OSingle ❑Dual III. TANK HISTORY Was Tank Tested? ❑ Yes 0 No Failed Testing? ❑ Yes ❑ No I]n/a If Yes, Provide Dates:n/a Was Tank System Repaired? ❑Yes❑NoE]n/a If Yes, Describe Repair: 0 n/a Was Repair Done Under Permit? ❑Yes❑No❑n/a Were Soil Samples Analyzed? I]Yes ❑ No BTEX IXI TPH-G ❑TPH-D ❑x LEAD ❑EDB IR VOCs Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑Overfill ❑ Unknown ❑ Other IV. REMOVAL HISTORY(Attach File Soil Samples Received? 0 Yes ❑ No Seasonal High Depth to GW ft bgs Year/Reference I Ni ( � Onsite and/or Nearby Well(s)? ❑Yes talo L3 Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑Domestic:# Distance to Tank ft 0 points if 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank ft R condition is R condition is R condition is met V. SITE FEATURE-LEACHING POTENTIAL ANALYSIS E met E met E Minimum Depth to Groundwater from Soil Sample(feet) >100 9 51 -100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) 10 None Unknown Present Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migration -------- None Unknown Present , i.e.septics stems,water wells,ponds) Unique Site Features:Recharge Area,Coarse Soil(coarse sands, None At Least One More Than One gravels),nearby wells Column Totals Total Points + + _ Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less Maximum Allowable BTEX B T E I X B T E X N/A3 Levels m 1.0 50 1 50 50 0.3 0.3 1.0 1.0 Sample Results for TPH: Maximum Gasoline 1,000 100 10 Allowable TPH Levels m Diesel 10,000 1,000 100 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). 1 If depth is>5 feet and<25 feet,score 0 points. If depth is-5 feet,do not use table. 2 If precipitation is>40 inches,score 0 points. 3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. VI. STAFF RECOMMENDATION/REFERRAL/REVIEW 1. Are BTEX or TPH Concentrations>Allowable Levels? 0 2. If No, Is Site Closure Recommended? &Yes ❑ No Completed By: Date Referred to Site Mitigation Unit for Final Actions Reviewed By: Concur with Staff Recommendation es ❑ No TAll Cases are Referred to Site Mitigation for Final Action Date Closure Letter Mailed (0-10-1(0 K� EH 23-0080(Rev 11/14/08)