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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I . FACILITYITANK INFORMATION DATE : I SITE/FACILITY NAME : (/l � m ii VGA ` f U � r QS 1 � ` VI C, STATUS CODE : �� "" ADDRESS: 2 Le LP rl (� Lia CITY: L r7 v 6/ FA#: 2 5 5 •�Y3 PR#: (Z2 G TANK # 39 2e '8 TANK SIZE : t-;15 U qaA FUEL TYPE : ga1 f n II . GENERAL SITE HISTORY ` Is Permit Current? Yes ❑ No ❑ NA Documented Soil/GW Contamination?*** ❑ Yes ❑ No Number of Tanks at Facility Age of Tanks (if available) Type of Tank Steel ❑ Fiberglass ❑ Single ❑ Dual III . TANK HISTORY Was Tank Tested ? ❑Yes No ❑ NA Failed Testing ? ❑ Yes ❑ No NA If Yes, Provide Dates : Was Tank System Repaired ? ❑Yes ❑ No NA If Yes , Describe Repair: Nit Was Repair Done Under Permit? ❑Yes ❑ No XNA Were Soil Samples Analyzed ? dyes LJNo L BTEX TPH-G TPH-D LEAD ❑ EDB ❑ OTHER ❑ OXYGENATES Type of Failure/Discharge : ❑ Catastrophic ❑ Long-term Leak ❑ Overfill fd Unknown ❑ Other IV, REMOVAL HISTORY Attach File Soil Samples Received ? .ZYes ❑ No Seasonal High Depth to GW ft bgs Year/ Reference Onsite and/or Nearby Well (s) ? dYes ❑ No Ll Irrigation : # Distance to Tank ft � Score 10 C Score 9 C wEMomestic: #._�_ Distance to Tank do ft 0 points if 0 points if 0 Score 5 points if LI 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 t 51 - 100 25 - 501 Fractures in Subsurface (applies to foothill or mountain areas) 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 Sample Results for BTEX: Range of Total Points 49 Points or More 41 — 48 Points 40 Points or Less B Maximum Allowable BTEX B T E X B T E X E Q Levels (ppm) 1 . 0 50 50 50 0 . 3 0 . 3 0 1 . 0 N/A3 X Sample Results for TPH : Maximum Gasoline 11000 100 10 Allowable TPH N Levels pm 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). 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/ REFERRALI REVIEW 1 . Are BTEX or TPH Concentrations > Allowable Levels? ❑ Yes XNo 2 . If No, Is Site Closure Recommended? PYYes ❑ No Completed By: � (nJ f♦ .li- p ��G11''�'G �t Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation ❑ Yes ❑ No Date Closure Letter Mailed tAII Cases are Referred to Site Mitigation for Final Action EH 23 -0080 (Rev 11/14/08)