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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: I 1727110 SITE/FACILITY NAME: P VVI - STATUS CODE: S ADDRESS: 61I CITY: FA# 363S PR# Z 3 l S 6. TANK#301-00 TANK SIZE: N/A K FUEL TYPE: r- 11. GENERAL SITE HISTORY Is Permit Current? x Yes ❑ No Documented Soil/GW Contamination?"' ❑ Yes Z No Type Number of Tanks at Facility 3 Age of Tanks(if available) 10 /11<�4 ❑Dualf Tank❑Steel .Fiberglass ❑Single III. TANK HISTORY Was Tank Tested? $ Yes ❑ No Failed Testing? ❑ Yes A No Yes,Provide Dates: Was Tank System Repaired? ❑ Yes No If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes )d No Were Soil Samples Analyzed? ❑Yes ❑ No ❑BTEX❑TPH-G❑TPH-D ❑LEAD ❑ EDB❑OTHER Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown ❑Other IV. REMOVAL HISTORY Attach File FI Soil Samples Received? X Yes LJ No Seasonal High Depth to GW ft bgs Year/Reference Sr✓�-'s i ny Onsite and/or Nearby Well(s)? ❑Yes K No L3 Irrigation: # Distance to Tank ft � Score 10 C Score 9 L3 Domestic:# Distance to Tank ft 0 points if 0 points if 0 Score 5 points if ❑ 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 Depth(feet)' >100 51 -100 Q 25-501 Fractures in Subsurface(applies to foothill or mountain areas) k P None Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 ------- 26-402 Man-Made Conduits which Increase Vertical Migration NoneUnknown Present i.e.septic sstems,water wells,ponds) 9 Unique Site Features: Recharge Area, Coarse Soil(coarse sands, io None At Least One More Than One gravels), nearby wells Column Totals — /0 "3y Total Points + (g +I?0AI/tA W 10 O = 3 Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less (fid Maximum Allowable BTEX B T E X B I T E X WA3 Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 Sample Results for TPH: Maximum Gasoline 1,000 100 10 Allowable TPH Levels m 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). 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. 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/REFERRAL/REVIEW 1. Are BTEX or TPH Concentrations>Allowable Levels? L]Yes J14 No 2. If No, Is Site Closure Recommended? Yes L3 No Completed By: yo , /%*/yvA Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation *Yes ❑ No Date Closure Lefler Mailed tAll Cases are Referred to Site Mitigation for Final Action *Subtract soil sample depth from groundwater depth to determine distance be sample depth and groundwater OK ?�- vJe s«l h"hi1/,• le 4.r,)cantor aFise'f. `�P�° u�..�r l� .*+ 1,C kZ j-"*J lCLAI-l� EH 23-0080(Rev6/4/20G' w//p/�6 �" /"r� 7•�lt i�i+� fri/ ,3�,(IOI��ytq � / S• �,�1 /� ,f o�� v�� r�h, PG / ✓