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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: <br /> SITEIFACILITY NAME: I Arco kM P WI 14-V 5�'b STATUS CODE: c <br /> ADDRESS: 6t CITY: <br /> FA# TANK# 'DI6 <br /> TANK SIZE: N/A lav- FUEL TYPE: mid <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? x Yes ❑ No Documented Soil/ W Contamination?*** ❑ Yes.l'No <br /> Number of Tanks at Facility2� Age of Tanks(if available) D r�Lf Type of Tank❑Steel iberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? .-9�Yes ❑ No Failed Testing? ❑ Yes•0'No Yes, Provide Dates: <br /> Was Tank System Repaired? ❑ Yes 12"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? X Yes ❑ No Seasonal High Depth to GW L) ft bgs Year/Reference Y f <br /> Onsite and/or Nearby Well(s)? ❑Yes,0'No <br /> LJ Irrigation: # Distance to Tank ft � Score 10 C Score 9 � <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 Depth(feet)* >100 51 -100 0 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) None <br /> Average Annual Precipitation(14 inches for SJC area) ------- <10 9 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, r O None At Least One More Than One <br /> ravels),nearb wells l <br /> Column Totals $r WAVI — I0 M Total Points '�(� + + _ 39 <br /> Sample Results for BTEX: W 4V <br /> Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less <br /> N Maximum Allowable BTEX B T E F—X --B T E X k, N/A3 <br /> Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 <br /> Sample Results for TPH: Maximum Gasoline 1,000 100 10 <br /> ff�J Allowable TPH <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 is­5 feet,do not use table. 2 If precipitation is>40 inches,score 0 points. <br /> L_ 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 �l0 2. If No, Is Site Closure Recommended? Yes ❑ No <br /> Completed By: 44 4/#W>9ADate Referred to Site Mitigation Unit for Final Actiont <br /> Reviewed By:Kq4 Concur with Staff Recommendation 92fYes ❑ No <br /> Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action <br /> *Subtract soil sample depth from groundwater depth to determine distance be sample depth and groundwater <br /> EH 23-0080(Rev6/4/2007) <br />