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SAN JOAQUIN C( NTY ENVIRONMENTAL HEA-..,,,,H DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION // <br /> I. FACILITY/TANK INFORMATION DATE: �` 00 / <br /> SITE/FACILITY NAME: (QYj - STATUS CODE: <br /> ADDRESS: �� Q/'1 �7�fCf C CITY: S�D <br /> FA#: 5 / PR#: TANK#L39 0/ & j&0 <br /> TANK SIZE: d2 O DQ FUEL TYPE: 2 S' <br /> Il. GENERAL SITE HISTORY <br /> Is Permit Current? 'X Yes ❑ No ❑ NA Documented Soil/GW Contamination?"* ❑ Yes o <br /> Number of Tanks at Facility :�7 Age of Tanks(if available) Type of Tank❑SteellKiberglass ❑Single <br /> 2 �Q� ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested?Aes ❑No ❑ NA Failed Testing? ❑Yes Xo ❑ NA If Yes,Provide Dates: <br /> Was Tank System Repaired?❑Yes Flo ❑ NA If Yes, Describe Repair: <br /> Was Repair Done Under Permit?❑Yes❑ No*A Were Soil Samples Analyzed? Yes ❑ No )ZITEXXTPH-G H-D LEAD❑EDB <br /> ❑ OTHER "127�XYGENATES <br /> Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown ❑ Other <br /> IV. REMOVAL HISTORY(Attach File) <br /> Soil Samples Received? ❑Yes ❑ No Seasonal High Depth to GW ft bgs Year/Reference 017 <br /> Onsite and/or Nearby Well(s)? ❑Yes gNO <br /> LI Irrigation: # Distance to Tank ft � Score 10 � Score 9 C <br /> ❑ Domestic:# Distance to Tank ft-- 0 points if 0 points if 0 Score 5 points if <br /> ❑ Public: # Distance to Tank ft R condition is R condition is R condition is met <br /> V. SITE FEATURE—LEACHING POTENTIAL ANALYSIS E met E met E <br /> Minimum Depth to Groundwater from Soil Sample(feet) >100 51 —100 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) j p None Unknown Present <br /> Average Annual Precipitation(14 inches for SJC area) -------- <10 04 10-25 -------- 26-402 <br /> Man-Made Conduits which Increase Vertical Migration None Unknown Present <br /> i.e. septic sstems,water wells, ponds <br /> Unique Site Features:Recharge Area, Coarse Soil(coarse sands, None At Least One More Than One <br /> gravels), nearby wells <br /> Column Totals Total Points O + + <br /> Sample Results for BTEX: Range of Total Points 49 Points or More —48 oin 40 Points or Less <br /> JN D <br /> B /v fJ <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 1,000 100 10 <br /> d 0 0 Allowable TPH Diesel 10,000 1,000 100 <br /> Levels m <br /> Footnotes: "`If documented soil and/or groundwater contamination is presen,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 gNo <br /> Completed By:s-(ZLCq Date Referred to Site Mitigation Unit for Final Actions <br /> Reviewed By: Concur with Staff Recommendation Yes ❑ No <br /> Date Closure Letter Mai ed tAll Cases are Referred to Site Mitigation for Final Action <br /> EH 23-0080(Rev 11/14/08) <br />