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SAN JOAQUIN COMITY ENVIRONMENTAL HEAL)rk DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: $!-Z6gff <br /> - <br /> SITE/FACILITY NAME: STATUS CODE: <br /> ADDRESS: CITY: <br /> FA#: /r! 51 g PR#: S 3 0 6,& TANK# 39 5 -9 b77 s7$67 <br /> TANK SIZE: ?�4%9-0 goo. %Dvc FUEL TYPE: �i�,� asali...- ,s�t�'� <br /> sl W 6-7 ) <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? ❑ Yes ❑ No Documented Soil/GW Contamination?" ❑ Yes ❑ No <br /> Number of Tanks at Facility Age of Tanks(if available) Type of TankVSteel ❑Fiberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑ Yes ❑ No Failed Testing? ❑ Yes ❑ No If Yes,Provide Dates: <br /> Was Tank System Repaired? ❑ Yes ❑ No If Yes, Describe Repair: <br /> Was Repair Done Under Permit? ❑Yes ❑ No Were Soil Samples Analyzed? ❑Yes ❑ No ❑BTEX❑TPH-G❑TPH-D ❑LEAD <br /> ❑EDB❑OTHER <br /> Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑Unknown ❑Other <br /> IV. REMOVAL HISTORY Attach File <br /> Soil Samples Received�Yes L3 No Seasonal High Depth to GW ft bgs Year/Reference g <br /> Onsite and/or Nearby Well(s)? ❑Yes'Tlo <br /> L3 Irrigation: # Distance to Tank ft � Score 10 C 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) None Unknown Present <br /> Average Annual Precipitation(14 inches for SJC area) ------- <10 9 10-25 ------- 26-402 <br /> Man-Made Conduits which Increase Vertical MigrationNone Unknown Present <br /> i.e.septic sstems,water wells,ponds) - <br /> Unique Site Features:Recharge Area,Coarse Soil(coarse sands, None 17 At Least One More Than One <br /> gravels),nearby wells <br /> Column Totals Total Points 1p + Z + 5 LfSample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less <br /> t3 nr D <br /> H p Maximum Allowable BTEXB T E X B T E X N/A3 <br /> Levels m 1.0 50 50 50 0.3 0.3 1 1.0 1.0 <br /> Sample Results for TPH: Maximum Gasoline 1,000 100 10 <br /> -TPH—Cr r`►D Allowable TPH <br /> TPH- D ".0 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 o <br /> Completed By: Date Referred to Site Mitigation Unit for Final Actiont <br /> Reviewed By: Concur with Staff Recommendation ❑Yes ❑No <br /> Date Closure Letter Mailed TAll Cases are Referred to Site Mitigation for Final Action L <br /> �i e(d 1J ObP5 C�-i�vr��c-)6z:6 as o f.rPcE <br /> �Jy ntrxolr>r��i� s0-1 6 ods <br /> EH 23-0080(Rev 11/14/08) <br /> `2,ar,P�e <br />