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SAN JOAQUIN CONTY ENVIRONMENTAL HEAW DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: 2 DSI SITE/FACILITY NAME: STATUS CODE: ADDRESS: CITY: FA#: ) (b PR# -3 TANK# 39 TANK SIZE: b FUEL TYPE: II. GENERAL SITE HISTORY Is Permit Current? Yes ❑ No Documented Soil/GW Contamination?*** Yes'fj,No Number of Tanks at Facility141 Age of Tanks(if available) N 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 71f Yes,Describe Repair: g� SeA &\�/ S ryt" L'cu 'S Was Repair Done Under Permit? ❑Yes No Were Soil Samples Analyzed? es L3No L3BTEX L3TPH-G L3TPH-D L3LEAD yy ❑EDB❑OTHER Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑Unknown ❑Other IV. REMOVAL HISTORY Attach File Soil Samples Received? es ❑No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes ❑No .+11N1/0 ❑ 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(feet) 4 >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.septic sstems,water wells, ponds) Unique Site Features:Recharge Area, Coarse Soil(coarse sands, 1 None At Least One More Than One gravels),nearbywells Column Totals Total Points 2"l + �� + _ r/ Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Loess U Maximum Allowable BTEX B I T ETX—B---[—T I E I X N/A3 Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 Sample Results for TPH: Maximum IGasoline 1,000 100 10 / Q P ,� 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 already on the contamination list). 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. 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 No 2. If No, Is Site Closure Recommended? L3 Yes No Completed By: UAIIA14Date Referred to Site Mitigation Unit for Final Actions 0 Reviewed By: Concur with Staff Recommendation Yes ❑ No Date Closure Letter Mailed sAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev6/4/2007)