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SAI_ JOAQUIN C NTY ENVIRONMENTAL HEk 'H DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: yWE. 0 SITEIFACILITY NAME: STATUS COD ADDRESS: CITY: FA#: PR#: TANK# 39 l TANK SIZE: 3C FUEL TYPE: S II. GENERAL SITE HISTORY Is Permit Current? ❑ Yes ❑ No A Documented Soil/GW Contamination?` ❑ Yes o Number of Tanks at Facility ( Age of Tanks(if available) 111 Type of Tank PZteel ❑Fiberglass IMingle ❑Dual III. TANK HISTORY Was Tank Tested? ❑Yes ❑No A I Failed Testing? ❑Yes ❑ No A If Yes, Provide Dates: Was Tank System Repaired?❑Yes 13NoIA If Yes,Describe Repair: Was Repair Done Under Permit?❑Yes❑ No_IA Were Soil Samples Analyzed? es ❑ No TE TPH-G PH-D DEAD LJEDB ��"" ❑ OTHER—AIOXYGENATES Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑ Overfillnknown *—Otherns�e- IV. REMOVAL HISTORY Attach File Soil Samples Received?"' ❑No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes)lo 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 0 Score 5 points if ❑ 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) to 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 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 tz) + `j 6 + ,.$wnple Results fo BBTE � Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less B N10 0&rn�f E T N 0, Maximum Allowable BTEX B T E X B T X 3 E (�,�?'3� 0,410 Levels(ppm) 1.0 50 50 50 0.3 0.3 0 1.0 N/A Xd, ample Results for Pfd; Maximum Gasoline 1,000 100 10 Tia 1 " Allowable TPH CT—35. G% _^ 0l Levels m Diesel 10,000 1,000 100 otn tes: "*If documented soi and/or groundwater contamination is present,do not complete leaching potential analysis(i.e.site is already on the contamination list). 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? Yes E3 No 2. If No, Is Site Closure Recommended? L3 Yes o Completed By: l Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: oncur with Staff Recommendation Eryes ❑ No Date Closure Letter Mailed r� tAll Cases are Referred to Site Mitigation for Final Action 7�3 ,,,9/1<1 na rgE 34 fa EH 23-0080(Rev 11/14/08)