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SAN JOAQUIN OUNTY ENVIRONMENTAL HATH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITY/TANK INFORMATION DATE: /2 16(66 SITE/FACILITY NAME: C / 6 OL lC n 2e DeU010p STATUS CODE: ADDRESS: U1 Q �- 1� -701 Vi, W 4(r Ave- - CITY: I Si Dczh� FA#: Ubb O I PR#:05Lg13f 1 39 DSI -7SK3 TANK SIZE: 1000 -F c90 I FUEL TYPE: UNVnp DSI -7675 II. GENERAL SITE HISTORY Is Permit Current? Yes ❑ No Documented Soil/GW Contamination?` ❑ Yes 0 No Type Number of Tanks at Facility Z Age of Tanks(if available) U N�o ❑Dualf Tank, feel ❑Fiberglass Ingle III. TANK HISTORY Was Tank Tested? ❑ Yes �[ No Failed Testing? ❑ Yes No If Yes, Provide Dates: Was Tank System Repaired? ❑ Yes ¢L No If Yes,Describe Repair: Was Repair Done Under Permit? ❑Yes`A No Were Soil Samples Analyzed? es El No BTEX WTPH-G t$TPH-D LEAD 7�'dyVEDBI$OTHER Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill)1 Unknown ❑ Other IV. REMOVAL HISTORY Attach File Soil Samples Received? KYes ❑No Seasonal High Depth to GW -L2�It bgs Year/Reference s 071, Onsite and/or Nearby Well(s)? ❑Yes OLNo TR S S ❑ Irrigation: #L— Distance to Tank_ ft 0 C Score 9 C ❑ Domestic:# Distance to Tank ft f 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank_ It is Rcondition is Rcondition is met V. SITE FEATURE—LEACHING POTENTIAL ANALYSIS 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 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.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 I O Sample Re /Its for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less TsoprWy ifjc•1VN I Maximum Allowable BTEX B T E X B T E X NIA3 N 0, �h A Lam-' ��6 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 3(OD Levels m Diesel 10,000 1,000 100 Footnotes: ***If documented soil andlor 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?XYes ❑ No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No Completed By: Vprf fCV(_, Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation ❑Yes ❑ No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev6/4/2007)