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SAN JOAQUIN ANTY ENVIRONMENTAL HEX"H DEPARTMENT <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION <br />I. FACILITYITANK INFORMATION DATE: <br />SITE/FACILITY NAME: r C (j�G�S STATUS CODE: <br />ADDRESS:CITY: % <br />FA#: 2� PR#: Z3 I ��� TANK # 39 <br />TANK SIZE: FUEL TYPE: <br />II. GENERAL SITE HISTORY <br />Is Permit Current? Yes ❑ No <br />Documented Soil/GW Contamination?"* ❑ Yes ❑ No <br />Number of Tanks at Facility <br />Was Tank System Repaired? ❑ Yes ❑ No <br />Age of Tanks (if available) <br />Was Repair Done Under Permit? ❑ Yes ❑ No <br />T pe of Tank ❑Steel ❑Fiberglass ❑Single <br />Dual <br />III. TANK HISTORY <br />Was Tank Tested? ❑ Yes ❑ No <br />Failed Testing? ❑ Yes 0 No <br />If Yes, Provide Dates: <br />Was Tank System Repaired? ❑ Yes ❑ No <br />If Yes, Describe Repair: <br />Was Repair Done Under Permit? ❑ Yes ❑ No <br />Were Soil Samples Analyzed? ❑ Yes ❑ No <br />❑ BTEX ❑ TPH-G ❑ TPH-D ❑ LEAD <br />❑ EDB ❑ OTHER <br />Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown ❑ Other <br />t1`A►APIlVl7G\n:IS1Mill ir_11e. Min aIr-7 <br />Soil Samples Received? ❑ Yes ❑ No <br />Seasonal High Depth to GW ft bgs <br />Year/ Reference <br />Onsite and/or Nearby Well(s)? ❑ Yes ❑ No <br />❑ Irrigation: # Distance to Tank ft <br />� <br />Score 10 <br />C <br />Score 9 <br />C <br />❑ Domestic: # Distance to Tank ft <br />0 <br />points if <br />0 <br />points if <br />0 <br />Score 5 points if <br />❑ Public: # Distance to Tank ft <br />R <br />E <br />condition is <br />met <br />R <br />E <br />condition is <br />met <br />R <br />E <br />condition is met <br />V. SITE FEATURE — LEACHING POTENTIAL ANALYSIS <br />Minimum Depth to Groundwater from Soil Sample (feet) <br />>100 <br />51 —100 <br />25-501 <br />Fractures in Subsurface (applies to foothill or mountain areas) <br />10None <br />— — <br />Average Annual Precipitation (14 inches for SJC area) <br />-------- <br /><10 <br />9 <br />10-25 <br />-------- <br />26-402 <br />Man -Made Conduits which Increase Vertical Migration <br />None <br />Unknown <br />Present <br />i.e. septic sstems, water wells,ponds) <br />Unique Site Features: Recharge Area, Coarse Soil (coarse sands, <br />None <br />At Least One <br />More Than One <br />gravels), nearby wells <br />Column Totals Total Points <br />+ <br />+ <br />5_ <br />Sample Results for BTEX: <br />Range of Total Points <br />49 Points or More <br />41 — 48 Points <br />40 Points or Less <br />Maximum Allowable BTEX <br />B <br />I T <br />E <br />I X <br />B <br />T <br />E <br />X <br />N/A3 <br />Levels pm <br />1.0 <br />50 <br />50 <br />50 <br />0.3 <br />0.3 <br />1.0 <br />1.0 <br />Sample Results for TPH: <br />Maximum <br />Gasoline <br />1,000 <br />100 <br />10 <br />Allowable TPH <br />Levels (ppm) <br />Diesel <br />10,000 <br />1,000 <br />100 <br />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). <br />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. <br />3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. <br />VI. STAFF RECOMMENDATION/ REFERRAL/ REVIEW 1 1 <br />1. Are BTEX or T H Concentrations > Allowab a Levels? C3 Yes XNo 2. If No, Is Site Closure Recomme ded? Yes ❑ No <br />Completed By: Date Referred to Site Mitigation Unit for Final Actiont <br />Reviewed By: ncur with Staff Recommendation QtYes ❑ No 1 <br />Date Closure Letter Mailed U V I 'All Cases are Referred to Site Mitigation for Final Action <br />EH 23-0080 (Rev6/4/2007) <br />