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SAN JOAQUIN C .JNTY ENVIRONMENTAL HEARj-I DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: SITE/FACILITY NAME: I �A A STATUS CODE: ADDRESS: 600 G - VUAtn St- CITY: I S G or FA#: RD 0!�OZPR#: o 4qe TANK#1 39 - Tf}ej 20417 I TANK SIZE: ';00 FUEL TYPE: W/1 0"i✓1 II. GENERAL SITE HISTORY Is Permit Current? ❑ Yes ❑ No ANA Documented Soil/GW Contamination?` Yes ❑ No Number of Tanks at FacilityAge of Tanks(if available) Type of Tank teel ❑Fiberglass ❑Single 1 ❑Dual III. TANK HISTORY Was Tank Tested? ❑Yes ❑No �(NA Failed Testing? ❑Yes ❑ No �LNA If Yes,Provide Dates: Was Tank System Repaired? ❑Yes ❑No IIA If Yes, Describe Repair: Was Repair Done Under Permit?❑Yes❑ No`*NA Were Soil Samples Analyzed? )&es ❑ No 1�11-BTEXPH-G �LTPH-D ZFLEAD EDB LJ0TH R OXYGENATES Type of Failure/Discharge: ❑Catastrophic ❑ Long-term Leak ❑ Overfill Unknown ❑Other IV. REMOVAL HISTORY Attach File Soil Samples Received? 0 Yes ❑ No Seasonal High Depth to GW 50 ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes d No El 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 E met E met E Minimum Depth to Groundwater from Soil Sample(feet) >100 51 -100 C- 25-501 Fractures in Subsurface(applies to foothill or mountain areas) None 9 Unknown Present Average Annual Precipitation (14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migration i.e.septic sstems,water wells,ponds) -- --- None Unknown Present Unique Site Features: Recharge Area,Coarse Soil(coarse sands, None At Least One More Than One gravels),nearby wells 10 Column Totals Total Points1(3 + Z7 + _ Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less B Z:L->CP6 xy(,,__5 T Maximum Allowable BTEX B T E X B T E X 3 E Levels(ppm) 1.0 50 50 50 0.3 0.3 0 1.0 N/A X Sample Results for TPH: Maximum Gasoline 1,000 100 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? ❑Yes.�No 2. If No, Is Site Closure RecommendedAQ7Yes ❑ No Completed By: Noc1 Dae Referred to Site Mitigation Unit for Final Actiont Reviewed By: /�` j �d Concur with Staff Recommendation Yes ❑ No io Z6 4 Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)