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SAN JOAQUIN CC&TY ENVIRONMENTAL HEAW DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EUATION I. FACILITY/TANK INFORMATION DATE: SITE/FACILITY NAME: CREVRoN Zo 1 383 STATUS CODE: ADDRESS: 19 (e 4 W, i I t` Sf- T j A L YA CITY: -M Ae- FA#: 000 1/5f7 PR#: 6 2 3 23 34 TANK#j 39 �} TANK SIZE: KA FUEL TYPE: Cas c I ` Y) e— ll. GENERAL SITE HISTORY Is Permit Current? W Yes ❑ No ❑ NA I Documented Soil/GW Contamination?*** ® Yes ❑ No Number of Tanks at FacilityAge Was Tank System Repaired? ®Yes LJ No LJ NA of Tanks (if available) :Z S 2 ,kO Type of Tank ❑Steel ZFiberglass ❑Single Dual III. TANK HISTORY Was Tank Tested? ❑Yes ❑No A NA Failed Testing? ❑ Yes ❑ No IN NA If Yes, Provide Dates: Was Tank System Repaired? ®Yes LJ No LJ NA If Yes, Describe Repair: j�� 1 Q Url er c�i S ��ae srev;qfGt i� T1s Was Repair Done Under Permit? ®Yes ❑ No ❑ NA Were Soil Samples Analyzed? ® Yes ❑ No 29 BTEX a TPH-G Z9 TPH-D 3 LEAD Z EDB W OTHER da h%dIene OXYGENATE M Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill B Unknown ❑ Other Rep I a 0 e— u rLd ow dis joa q 01YA: 4�AXT/114:163LSIXt/_1;PR771M Soil Samples Received? a Yes ❑ No Seasonal High Depth to GW ft bgs Year/ Reference Onsite and/or Nearby Well(s)? ❑ Yes ❑ No Ll 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) /0 >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)V �a<< zi :' 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 E B p,co 50 m�IK )�4 T< 0, co5o 5 Maximum Allowable BTEX E O. Ut o Y(14'2Ph}KQlene of Levels (ppm) B 1.0 T 50 E 50 X 50 B 0.3 T 0.3 X 1.0 N/A 3 � 0 X 0,041 Sample Results for TPH: Maximum Gasoline 1,000 100 10 Gas Z I k9 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 aready 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? ❑ Yes a No 2. If No, Is Site Closure Recommended? ® Yes ❑ No Completed By: V1'e K', Date Referred to Site Mitigation Unit for Final Actiont z Reviewed By: Concur with Staff Recommendation ❑ Yes ❑ No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080 (Rev 11/14/08) i 2�S