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SAN JOAQUIN C'' JNTY ENVIRONMENTAL HEA` H DEPARTMENT UST WORKSHEET FOR SITE CLOSURE 07ALUATION I. FACILITYrrANK INFORMATION I DATE: 191244DGI SITE/FACILITY NAME: STATUS CODE: ADDRESS: CITY: FA#: D I PRH 3!]A# 39 TANK SIZE: 0 cap FUEL TYPE: ll. GENERAL SITE HISTMY Is Permit Current? X Yes ❑ No Documented Soil/GW Contamination?` Yes No Number of Tanks at Facility14 1 Age of Tanks(if available) N Tye of Tank Steel Fiberglass ❑Single R 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: ` Sp�S 0\12/ C 11'tGt,Ui L&b&'S Was Repair Done Under Permit? ❑YesNo Were Soil Samples Analyzed? es L3No ❑BTEX❑TPH-G L3TPH-D C3 LEAD ❑ na❑ETHER 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 ItYW-011 ✓ ❑Irrigation: # Distance to Tank_ ftFR Score 10 S Score 9 S CI Domestic:# Distance to Tank ft points if points if Score 5 points if L3 Public: # Distance to Tank_ ft condition is condition is condition is met V. SITE FEATURE-LEACHING POTENTIAL ANALYSIS met E met E Minimum Depth to Groundwater from Soil Sample(feet) L 5 >100 51 -100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) l 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 .e.septic sstems,water wells,ponds) -- Unique Site Features:Recharge Area, Coarse Soil(coarse sands, gravels),nearby wells I None At Least One More Than One Column Totals Total Points + + U 1 _ 3 W Sample Results for BTEX: Range of Total Points 49 Points or More 4pa ess fv L Maximum PJlowable BTEX B T E X B Levels m 1.0 50 50 50 0.3 SampleResults for TPH: Maximum Gasoline 1,000 AlLevablleTels mH Diesel 10,000 Footnotes: "*If documented soil and/orgruundwater 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 am 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? ❑Yes No Completed By: kA A I JA Jjj " Date Referred to Site Mitigation Unit for Final Actiont D 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(Rev6/42007)