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SAN JOAQUIN C.TY ENVIRONMENTAL HEAjjH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE E LUATION I. FACILITY/TANK INFORMATION I Documented Soil/GW Contamination?" Q Yes ❑ No Number of Tanks at Facility Was Tank System Repaired? ZlYes ❑ No ❑ NA DATE: I Z/If .20 1(' SITE/FACILITY NAME: C H E V R ON .20) 3 8 3 STATUS CODE: ADDRESS: 19 b 0 t0. &S ' Tra CITY: I T �a � FA#: a oo 1131t 7 L3 Irrigation: # Distance to Tank ft PR#: 0 2 3.2 34 Score 10 TANK #139 N( TANK SIZE: A II (:FWFRAI CITE NICTORV FUEL TYPE: ❑ Domestic: # Distance to Tank ft Is Permit Current? 3 Yes ❑ No ❑ NA I Documented Soil/GW Contamination?" Q Yes ❑ No Number of Tanks at Facility Was Tank System Repaired? ZlYes ❑ No ❑ NA Age of Tanks (if available) 2 5 `y Type of Tank ❑Steel JRFiberglass ❑Single III. TANK HISTORY Was Tank Tested? ❑Yes ❑No ® NA Failed Testing? ❑ Yes ❑ No a NA If Yes, Provide Dates: Was Tank System Repaired? ZlYes ❑ No ❑ NA If Yes, Describe Repair: S+ ; rep laces S 6y7s Was Repair Done Under Permit? BYes ❑ No ❑ NA Were Soil Samples Analyzed? I3 Yes ❑ No ® BT6 13 TPH-G UTPH-D 2 LEAD.0 EDB E&OTHERr a ) QOXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ® Unknown ❑ Others e,2da Y 6 n' u•�:� � �� r•1,�i�� ■:I I,� r•�:� n�� Fra � �t r-a� T6 Iy z's Soil Samples Received? 5d Yes ❑ No Seasonal High Depth to GW ft bgs Year/ Reference Onsite and/or Nearby Well(s)? ❑ Yes ❑ No L3 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 E condition is met R E condition is met R E condition is met V. SITE FEATURE - LEACHING POTENTIAL ANALYSIS Minimum Depth to Groundwater from Soil Sample (feet) Q >100 51-100 25-501 Fractures in Subsurface (applies to foothill or mountain areas) None Unknown Present 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. 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 + + _ BTE�X` B Sample Results Q C- Q1� 'K Range of Total Points 49 Points or More 41- 48 Points 40 Points or Less E T C o, v o 5_6 m8 ) KS Maximum Allowable BTEX B T E X B T X N/A3 Levels m 1.0 50 50 50 0.3 0.3 0 1.0 X f 0,006-0 )C Sample Results for PH: Maximum Gasoline 1,000 1 100 10 Cas _1 t - O ,rto i Kj Allowable TPH D' �'�� -",1, 0 I 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). 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? ❑ Yes V No 72. If No, Is Site Closure Recommended? 3 Yes ❑ No Completed By: , , Date Referred to Site Mitigation Unit for Final Actiont Reviewed By:-�'��,, Concur with Staff Recommendation WYes ❑ No X, el'e, e;4d4-"- Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080 (Rev 11/14/08)