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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITYITANK INFORMATION DATE: 8 <br /> SITE/FACILITY NAME: I-b )gU ro fb b /O/U a N K STATUS CODE: <br /> ADDRESS: loll <br /> FA# '1132( PR# Iq I TANK# <br /> TANK SIZE: N/A FUEL TYPE: <br /> IL GENERAL SITE HISTORY <br /> Is Permit Cur x Yes ❑ No Documented Soil/GW Contamination?` ❑ Yes ❑ No <br /> Number of Tanks at lity Age of Tanks(if available) Type of Tank❑Steel ❑Fiberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank ed? ❑ Yes ❑ No Failed Testing? ❑ Yes ❑ No If Yes,Provide Dates: <br /> Was Tank System aired? ❑ Yes ❑ No If Yes,Describe Repair: <br /> Was Repair Done Under"P it? ❑Yes ❑ No Were Soil Samples Analyzed? ❑Yes ❑ No L3 BTEX❑TPH-G TPH-0 ❑LEAD <br /> ❑EDB❑OTHER <br /> Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑ Overfill ❑Unknown ❑Other <br /> IV. REMOVAL HISTORY Attach File <br /> Soil Samples eived? x Yes ❑ No Seasonal High Depth to GW It bgs Year/Reference <br /> Onsite and/or Nearb ell(s)? ❑Yes ❑ No S S S <br /> ❑ Irrigation: # Distance to Tank_ ft C Score 10 C Score 9 C <br /> ❑Domestic:# Distance to Tank ft 0 paints if 0 points if 0 Scare 5 points if <br /> ❑Public: # tance to Tank_ It 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 Depth(feet)' >100 51-100 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) one <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 /> i.e.septic sstems,water wells,ponds) <br /> Unique Site Features: Recharge Area,Coarse Soil(coarse sands, /O None At Least One More Than One <br /> gravels),nearby wells <br /> Column Totals Total Points �0 + /8 + S = k/3 <br /> Sample Results for BTEX: Range of Total Points 49 Points or More 41-48 Points 40 Points or Less <br /> Maximum Allowable BTEX B T E X B T E I X N/A3 <br /> Levels(ppm) 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 /> Levels(ppm) Diesel 10,000 1,000 000 100 <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,score 0 points. if depth is<=5 feet,do not use table. 2 I precipitation is>40 inches,scare 0 points. <br /> 3 Levels for BTEX are not applicable at a concentration of 10 ppm forTPH—Gasoline or 100 ppm forTPH-Diesel. <br /> VI. STAFF RECOMMENDATION/REFERRAL/REVIEW <br /> 1. Are BTEX or TPH Concentrations>Allowable Levels? A Yes ❑No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No <br /> Completed By: 16A64 01 Date Referred to Site Mitigation Unit for Final Actiont <br /> Reviewed By: Concur with Staff Recommendation ❑Yes ❑ No <br /> Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action <br /> *Subtract soil sample depth from groundwater depth to determine distance be sample depth and groundwater <br /> EH 23-0080(Rev6/4=07) <br />