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SAN JOA4 UIN CONTY ENVIRONMENTAL HEAPH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: Z 1 SITE/FACILITY NAME: cd_6r� 0 aAA STATUS CODE: ADDRESS: 11vc11 L D�e " 66-c- CITY: �Gc.QF�I FA# ()00 0,2_7 61 PR# QZ-S1411i I Q2-S14TANK# TANK SIZE: N/A FUEL TYPE: ll. GENERAL SITE HISTORY Is Permit Current? X Yes ❑ No Documented Soil/GW Contamination?*** ❑ Yes U No Number of Tanks at FacilityZ Age of Tanks(if available) Type of Tank❑Steel ❑Fiberglass ❑Single ❑Dual III. TANK HISTORY Was Tank Tested? ❑ Yes ❑ No Failed Testing? ❑ Yes ❑ No If Yes, Provide Dates: Was Tank System Repaired? ❑ Yes ❑ No If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes ❑ 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 Soil Samples Received? X Yes ❑ No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes ❑ No LI Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑ Domestic:# Distance to Tank ftO points if 0 points if 0 Score 5 points if E3 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 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 Unknown Present i.e.septics stems,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 + + _ Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less Maximum Allowable BTEX B T EX -B--T E X N/A3 Levels m 1.0 50 50 50 0.3 1 0.3 1.0 1.0 Sample Results for TPH: Maximum Gasoline 1,000 100 10 Allowable TPH Levels ppm 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? E3 Yes ;l No 2. If No, Is Site Closure Recommended? �7Yes L3 No Completed By: , A,,* Date Referred to Site Mitigation Unit for Final Actiont AJ/A Reviewed By' Concur with Staff Recommendation W-Y6❑ No Date Closure Letter Mailed 1All 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)