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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: Lodi FA#: FA0023349 PR#: PR0540845 TANK# 39-0520795 TANK SIZE: 350 gallons FUEL TYPE: 87 regular gasoline II. GENERAL SITE HISTORY Is Permit Current? ❑ Yes ❑ No I] n/a Documented Soil/GW Contamination?*** ❑ Yes IHI 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 I] No Failed Testing? ❑ Yes ❑ No I]n/a If Yes,Provide Dates:n/a Was Tank System Repaired? ❑Yes❑NoZ n/a If Yes,Describe Repair: 0 n/a Was Repair Done Under Permit? L3 Yes❑No❑ n/a Were Soil Samples Analyzed? El Yes ❑ No L3 BTEX OO TPH-G L3TPH-D ❑x LEAD p p y ❑ EDB I] VOCs Type of Failure/Discharge: ❑Catastrophic ❑ Long-term Leak ❑ Overfill ❑Unknown ❑Other IV. REMOVAL HISTORY(Attach File Soil Samples Received? I]Yes ❑ No Seasonal High Depth to GW =ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes ;§No S S S ❑ Irrigation: # Distance to Tank ft C Score 10 C Score 9 C ❑Domestic:# Distance to Tank ft 0 points if 0 points if O Score 5 points if LJ 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 51 -100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) 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 9 Unknown Present i.e.septic sstems,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 + _ 46 Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less Maximum Allowable BTEX B T I E X B T I E I X N/A3 Levels m 1.0 50 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). I 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? fifes)4 No 2. If No, Is Site Closure Recommended? 6Kes ❑ No Completed By: Date Referred to Site Mitigation Unit for Final Actiont Reviewed B . � Concur with Staff Recommendation es ❑ No Date Closure Letter Mailedb'I('}-((0 tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)