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SAN JOAQUIN Cj%4NTY ENVIRONMENTAL HEA�H DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: SITE/FACILITY NAME: STATUS CODE: - ADDRESS: S CITY: �tT FAM PR#: ff TANK# 39 0, 15 TANK SIZE: -3 FUEL TYPE: $ 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) e A Type of Tank teel ❑Fiberglass ingle ❑Dual III. TANK HISTORY Was Tank Tested? OYes ONo A Failed Testing? ❑Yes ❑ No A If Yes,Provide Dates: Was Tank System Repaired?❑Yes ❑ No�A If Yes, Describe Repair. Was Repair Done Under Permit?❑Yes❑ NoJA Were Soil Samples Analyzed? es O No TE H-G PH-D CIREAD❑EDB ❑ OTHER XYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill nknown Other (tis�i i IV. REMOVAL HISTORY Attach File Soil Samples Received?)fes ❑ No Seasonal High Depth to GW It bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes�00 LlIrrigation: # Distance to Tank ft SScore 10 S Score 9 S El Domestic:# Distance to Tank_ ft CO points if CO points if CO Score 5 points if L]Public: # Distance to Tank it 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) Q 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 cl 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) + 36 = 6 $ampletResults104, C Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less B N`0S N D E D ^5 r T N 0,45 Maximum Allowable B T E X B T 1. X N/A3 E t7.c� y .,. O,L)(0 Levels(ppm) 1.0 50 50 50 0.3 0.3 01.0 X d, 57 1 Sarple Results for TP y Maximum Gasoline 1,000 100 10 K 1 SI�Y`1� Allowable TPH �' 3 •� G_ a3 Levels(ppm) Diesel 10,000 1,000 100 Jllboto tes: **"If documented soi and/orgroundwatercontamination 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/REFERRAU REVIEW 1. Are BTEX or TPH Concentrations>Allowable Levels? Yes ❑ No 2. If No, Is Site Closure Recommended? L3 Yes o Completed By: .� ,� Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: 8oncur with Staff Recommendation ErYes ❑ No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action z 34 rn.k EH 23-0080(Rev 11/14/08)