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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: S 9 I I <br /> SITEIFACILITY NAME: Lt YVIO Vxk co, STATUS CODE: <br /> ADDRESS: 320 W iiS MOWifeClt CITY: <br /> FA#: 20-7 PR#: (�OS36tl TANK# 39 - 05-LOIz3 <br /> TANK SIZE: 2,o00 Ghu on)s FUELTYPE: u unlcNowN <br /> It. GENERAL SITE HISTORY <br /> Is Permit Current? Id Yes ❑ No Documented Soil/GW Contamination?'• ❑ Yes ❑ No <br /> Number of Tanks at Facility Age of Tanks(if available) Wd wbo N Type of TankIdSteel ❑Fiberglass ❑Single <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑ Yes N No Failed Testing? ❑ Yes ❑ No If Yes,Provide Dates: <br /> Was Tank System Repaired? ❑ Yes 1A No If Yes,Describe Repair: <br /> Was Repair Done Under Permit? ❑Yes ❑ No Were Soil Samples Analyzed? ❑Yes ❑No LlBTEX C3TPH-G L3TPH-D C3LEAD <br /> ❑EDB❑OTHER <br /> Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑Unknown ❑Other <br /> IV. REMOVAL HISTORY Attach File <br /> Soil Samples Received? X Yes ❑No Seasonal High Depth to GW 7D It bgs Year/Reference lot-is <br /> Onsite and/or Nearby Well(s)? ❑Yes C%No <br /> Ll Irrigation: # Distance to Tank_ It S Score 10 S Score 9 S <br /> Ll # Distance to Tank_ ft 0 points if C points if 0 Score 5 points if <br /> ❑Public: # Distance to Tank_ ft R condition is R condition is R condition is met <br /> V. SITE FEATURE-LEACHING POTENTIAL ANALYSIS E met E met E <br /> Minimum Depth to Groundwater from Soil Sample(feet) >100 51 -100 0 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) Q None Unknown Present <br /> Average Annual Precipitation(14 inches for SJC area) -- <10 9 10-25 26-402 <br /> Man-Made Conduits which Increase Vertical Migration __- None Unknown Present <br /> .e.septic sstems,water wells,ponds) <br /> Unique Site Features:Recharge Area,Coarse Soil(coarse sands, None At Least One More Than One <br /> ravels ,nearb wells <br /> Column Totals Total Points ID + 01 + = X9 <br /> Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less <br /> On all �uow�(Cz DOS Ma>umum Allowable BTEX B T E X B T E X NIA3 <br /> Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 <br /> Sample Results for TPH: Maximum Gasoline 1,000 100 10 <br /> S1-STk=� b 5-3= <I Allowable TPH <br /> S2 c I b <br /> Stfs(/c=3D Levels m Diesel 10,000 1,000 100 <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 /> 1 If depth is>5 feet and<25 feet scone 0 points. If depth is 4=5 feet,do not use table. 21f precipitation is>40 inches,score 0 points. <br /> 3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPline or 100 ppm for TPH-Diesel. <br /> VI. STAFF RECOMMENDATION/REFERRAL/REVIEW <br /> 1. Are BTEX or TPH Concentrations>Allowable Levels? e UAo 1 2. If No, Is Site Closure Recommended? 5Wes <br /> ❑ No <br /> Completed By: roun t cf Afa(dM Date Referred to Site Mitigation Unit for F5PI Actions <br /> Reviewed By: Concur with Staff Recommendation Yes ❑No <br /> Date Closure Letter Mailed tAll Cases ane Referred to Site Mitigation for Final Action I I <br /> I�l� Una n))1' 7 rm c <br /> S_1-Stk. <br /> EH 23-0080(Rev 11/14/08) S—qq 12 �7 <br /> 1 ) 1 <br /> S 'bA 7 1 7 ,1 <br />