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SAN JOAQUIN C01AITY ENVIRONMENTAL HEAL141 DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: <br /> SITE/FACILITY NAME: STATUS CODE: <br /> ADDRESS: 45 4- N 9 17 CITY: 7�c <br /> FA#: 1 g PR#: 55o Z6 TANK# 39 <br /> TANK SIZE: p FUEL TYPE: <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? ❑ Yes ❑ No Documented Soil/GW Contamination?*'"" ❑ Yes ❑ No <br /> Number of Tanks at Facilityj� Age of Tanks(if available) Type of TankWteel ❑Fiberglass Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑ Yes ❑ No T 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 /> PL3 EDB❑OTHER <br /> Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑Unknown ❑Other <br /> IV. REMOVAL HISTORY Attach File <br /> Soil Samples Received?:i�es ❑ No Seasonal High Depth to GW _&c- ft bgs Year/Reference 9�3 <br /> Onsite and/or Nearby Well(s)? ❑Yes)'No S S S <br /> ❑ Irrigation: # Distance to Tank ft C 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) /p 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 Migration None UnknownS Present <br /> i.e.septic sstems,water wells, ponds 5•� -�� d-f ,,r f- <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 + Z.� + <br /> ample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less <br /> ryb M 9 Maximum Allowable BTEX B E X B T E X N/A3 <br /> ,el Levels p m 1.0F—T <br /> 50 50 50 0.3 0.3 1.0 1.0 <br /> Sample Results for TPp: Maximum Gasoline 1,000 100 10 <br /> -T`fPN_Cs- D Allowable TPH <br /> Diesel 10,000 1,000 100 <br /> 0 gLa. Levels m <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 /> 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 /> 3Levels 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*0 <br /> Completed By: Date Referred to Site Mitigation Unit for Final Actionf /�3 i I Os- <br /> Reviewed By: Concur with Staff Recommendation ❑Yes ❑No <br /> Date Closure Letter Mailed 1AII Cases are Referred to Site Mitigation for Final Action <br /> EH 23-0080(Rev 11/14/08) <br />