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SAN JOAQUIN C v)NTY ENVIRONMENTAL HEA, H DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: <br /> SITE/FACILITY NAME: STATUS CODE: <br /> ADDRESS: CITY: sivd-I� <br /> FA#: PR#: / 0-1 '?- ;e TANK# 39 <br /> TANK SIZE: U OO FUEL TYPE: <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? ',14 Yes ❑ No ❑ NA Documented Soil/GW Contamination?*** ❑ Yes o <br /> Number of Tanks at Facility 2 Age of Tanks(if available) -� Type of Tank❑SteelWiberglass ❑Single <br /> �lZ ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? Yes ❑No ❑ NA Failed Testing? ❑Yes 04-4o ❑ NA If Yes, Provide Dates: <br /> Was Tank System Repaired? ❑Yes 12114Jo❑ NA If Yes, Describe Repair: <br /> Was Repair Done Under Permit?❑Yes❑ No*NAJ Were Soil Samples Analyzed?; Yes ❑ No 7:31TEX TPH-G H-D ALEAD❑EDB <br /> ❑ OTHER 'UOOXYGENATES <br /> Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown ❑ Other <br /> IV. REMOVAL HISTORY(Attach File) <br /> Soil Samples Received? LJ Yes Ll No Seasonal High Depth to GW ft bgs Year/Reference <br /> Onsite and/or Nearby Well(s)? ❑Yes 4No <br /> Ll Irrigation: # Distance to Tank ft � Score 10 C Score 9 C <br /> ❑ Domestic:# Distance to Tank ft 0 points if O points if 0 Score 5 points if <br /> LJ Public: # Distance to Tank ft R condition is R condition is R condition is met <br /> met met <br /> 30TENTIAL ANALYSIS E E E <br /> ,Nc�Pg m Soil Sample(feet) >100 51 -100 25-501 <br /> Ates foothill or mountain areas) 0 None Unknown Present <br /> ches for SJC area) -------- <10 10-25 -------- 26-402 <br /> 17 ft rt 'Vertical Migration None Unknown Present <br /> ids <br /> 'a, Coarse Soil(coarse sands, None I At Least One More Than One <br /> iavcw iicdlU We115 I <br /> Column Totals Total Points C j + + _ ✓� <br /> Sample Results for BTEX: Range of Total Points 49 Points or More -41 48 oin 40 Points or Less <br /> B <br /> T Maximum Allowable BTEX B T E X B T E X N/A3 <br /> E Levels(ppm) 1.0 50 50 50 0.3 0.3 1.0 1.0 <br /> X <br /> Sample Results for TPH: Maximum Gasoline 11,000 100 10 <br /> 0 0 C) Allowable TPH `1� <br /> Levels m Diesel 10,000 1,000 100 <br /> 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). <br /> 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. <br /> 3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. <br /> VI. STAFF RECOMMENDATION/REFERRAL/REVIEW <br /> 1. Are BTEX or TPH Concentrations>Allowable Levels? &Yes ❑ No 2, If No, Is Site Closure Recommended? ❑Yes pf-No <br /> Completed By:s--t��, JQIVQ.tf�_. Date Referred to Site Mitigation Unit for Final Actions <br /> Reviewed By: Concur with Staff Recommendation *Yes Ll No <br /> Date Closure Letter Mailed sAll Cases are Referred to Site Mitigation for Final Action <br /> EH 23-0080(Rev II/14/08) <br />