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SAN JOAQUIN OWONTY ENVIRONMENTAL HEA`YH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION 1. FACILITY/TANKINFORMATION DATE: I it 112,1oq SITE/FACILITY NAME: STATUS CODE: ADDRESS: 2�.fi S (� CITY: FA# ff PR# 1)2,3(4gZ TANK# 05'04-,54,`77 TANK SIZE:r `.A (9-761—e FUEL TYPE: 0 II. GENERAL SITE HISTORY Is Permit Current? x Yes Q No Documented Soil/GW Contamination?" ❑ Yes 19 No Number of Tanks at Facility3 Age of Tanks(if available) Type of Tank NSteel ❑Fiberglass ❑Single ual Qakd III. TANK HISTORY Was Tank Tested? 51 Yes ❑ No Failed Testing? ❑ Yes ® No Fif Provide Dates: Was Tank System Repaired? ❑ Yes ® No If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes ❑ No Were.Soil Samples Analyzed? J4 Yes ❑ No W BTEX®TPH-G A TPH-D ❑LEAD !9 EDB 12 OTHER D Type of Failure/Discharge: ❑Catastrophic ❑ Long-term Leak ❑Overfill 0 Unknown ❑Other IV. REMOVAL HISTORY Attach File Soil Samples Received? x Yes ❑No Seasonal High Depth to GW ft bgs Year/Reference J Q Q 3 Onsite and/or Nearby Well(s)? ❑Yes �LNo Z3 Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑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 0 25-501 Fractures in Subsurface(applies to foothill or mountain areas) () None Average Annual Precipitation(14 inches for SJC area) ------- <10 9 10-25 ------- 26-402 Man-Made Conduits which Increase Vertical Migration None C1 Unknown Present i.e.septic sstems,water wells,ponds) Unique Site Features:Recharge Area, Coarse Soil(coarse sands, None At Least One More Than One gravels),nearby wells Column Totals Total Points p + a-1 + 3-r Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less ��5 Maximum Allowable BTEX B T E X B T ETX N/A3 Levels m 1.0 50 50 50 0.3 0.3 1.0 .0 Sample Results for TPH: Maximum Gasoline 1,000 100 10 9P6 r -71 Allowable TPN T>/65C-L 2vCs� Levels(ppm) Diesel 10,000 1,000 100 Footnotes: ***If documented soil aridlor groundwater contamination is present,do not complete leaching potential analysis(i.e.site is already on the contamination list). I 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? XYes ❑No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No Completed By: IM. PAI D--L-A Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: 9- qLA. Concur with Staff Recommendation 30 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 EH 23-0080(Rev6/4/2007)