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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL11.1 DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: II 0 V <br /> SITE/FACILITY NAME: SAn6UJ10 STATUS CODE: <br /> ADDRESS: Al nj%J CITY: I FAWING, <br /> FA#; I-" I PR#:0S 7ZF`/1 1 TANK#F 39--05I$?1 <br /> TANK SIZE: '2­5D 6ntI, FUEL TYPE: uNk4wom <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? ❑ Yes a No Documented SoiVGW Contamination?' ❑ Yes ❑ No <br /> Number of Tanks at Facility Age of Tanks(if available) Type of Tank®Steel ❑Fiberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑ Yes 111 No Failed Testing? ❑ Yes ❑ 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? ❑Yes ❑ No ❑BTEX❑TPH-G❑TPH-D ❑LEAD <br /> ❑Eos❑OTHER <br /> Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑ Overfill ❑ Unknown ❑Other <br /> IV, REMOVAL HISTORY Attach File <br /> Soil Samples Received? ®Yes ❑ No Seasonal High Depth to GW 20 ft bgs I Year/Reference <br /> Onsite and/or Nearby Well(s)? ❑Yes ❑No S S S <br /> E3Irrigation: # Distance to Tank_ It C Score 10 C Score 9 0 <br /> 13Domestic:# Distance to Tank It 0 points if 0 points if O Score 5 points if <br /> L1Public: # 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 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) (0 None <br /> Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 --- 26-402 <br /> Man-Made Conduits which Increase Vertical Migration None Of Unknown Present <br /> i.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),nearby wells <br /> Column Totals Total Points 10 + = <br /> Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less <br /> ND Maximum Allowable BTEX B T I E X B T E X N/A3 <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 /> Allowable TPH <br /> ND Levels m Diesel 10,000 1,000 100 <br /> Footnotes: ""11 documented soil andlorgroundwater 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 feat score 0 points. If depth is<=5 feet,do not use table. 2 If preapitation 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 /> A. STAFF RECOMMENDATION/REFERRAL/REVIEW <br /> 1. Are BTEX or TPH Concentrations>Allowable Levels? ❑Yes ❑No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No <br /> Completed By: 111/ r {J Pfl Date Referred to Site Mitigation Unit for Final Actions <br /> Reviewed By: - Concur with Staff Recommendation es ❑ No <br /> Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action <br /> EH 23-0080(Rev6/42007) <br />