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SAN JOAQUIN COTY ENVIRONMENTAL HEA 'i DEPARTMENT UST WORK9WEET FOR SITE CLOSURE EVNLUATION I. FACILITYITANK INFORMATION DATE: — SITE/FACILITY NAME: �Q f QUO STATUS CODE: ADDRESS: �j CITY: r{1tLtl00 FA#: [ PR#: W TANK# 39 TANK SIZE: (� FUEL TYPE: Reoullar N01 IL GENERAL SITE HISTORY ! Is Permit Current? Ar Iyes ❑ No ❑ NA Documented Soil/GW Contamination?*** ❑ Yes ❑ No Number of Tanks at Facility Age of Tanks(if available) Type of Tank❑Steel Kiberglass ❑Single ❑Dual III. TANK HISTORY Was Tank Tested? ❑Yes o ❑ NA Failed Testing? ❑Yes No LINA If Yes, Provide Dates: Was Tank System Repaired? Yes No ❑ NA If Yes, Describe Repair: `T a Was Repair Done Under Permit? Yes ❑ No❑ NA Were Soil Samples Analyzed?xYes ❑ No TEx PH-G Ll _4LEAD LJEDB ❑ OTHER OXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown Xother lotp (rYl Q,d IV. REMOVAL HISTORY Attach File Soil Samples Received?AYes ❑ No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes 1A No LJ Irrigation: # Distance to Tank ft � 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 I 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) None q 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, n None At Least One More Than One gravels), nearbywells V Column Totals Total Points I O + o+y q l + 0 _ :3 Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points �J40 Points or Less B E T Maximum Allowable BTEX B T E X B T X 3 E Levels(ppm) 1.0 50 50 50 0.3 0.3 0 1.0 NIA X Sample Results for TPH: Maximum Gasoline 11,000 100 10 Allowable TPH Levels m Diesel 10,000 1,000 100 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). 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?(Akes No 2. If No, Is Site Closure Recommended? es ❑ No Completed By: e w (� Date Referred to Site Mitigation Unit for Final Actiont Reviewed B . � ��,� - Concur with Staff Recommendation Yes Ll No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)