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41 <br /> SAN JOAQUIN CO 4tNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITYITANK INFORMATION DATE: ) 14 <br /> SITE/FACILITY NAME; STATUS CODE: <br /> ADDRESS: S < C CITY: <br /> FA#`. I PR#:Dt35&Q 18TANK# 39 2 1 <br /> TANK SIZE: FUEL TYPE: We <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? A Yes ❑ No Documented Soil/GW Contamination?*** ❑ YesA No <br /> Number of Tanks at Facility Age of Tanks(if available) Type of Tank Xteel ❑Fiberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑ Yes No Failed Testing? ❑ Yes ❑ No r' Pt If Yes, Provide Dates: N JA <br /> Was Tank System Repaired? ❑ Yes XNo If Yes, Describe Repair: NIA <br /> Was Repair Done Under Permit? ❑Yes o Were Soil Samples Analyzed? Yes ❑ No BTEX TPH-G LJTPH-D X LEAD <br /> L3 EDB OTHER Nafi <br /> Type of Failure/Discharge: ❑Catastrophic ❑ Long-term Leak ❑Overfill ❑Unknown ❑Other <br /> IV. REMOVAL HISTORY Attach File <br /> Soil Samples Received? Yes ❑ No Seasonal High Depth to GW ft bgs Year/Reference - <br /> 4 <br /> Onsite and/or Nearby Well(s)? ❑Yes ❑ No <br /> Ll Irrigation: # Distance to Tank ft � Score 10 C Score 9 C <br /> ❑ Domestic:# Distance to Tank ft 0 points if 0 points if 0 Score 5 points if <br /> LJ Public: # Distance to Tank ft R condition is R condition is R condition is met <br /> V. SITE FEATURE—LEACHING POTENTIAL ANALYSIS E met E met E <br /> Minimum Depth to Groundwater from Soil Sample(feet) >100 51 -100 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) None Unknown Present <br /> Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 <br /> Man-Made Conduits which Increase Vertical Migration NoneUnknown Present <br /> i.e.septic sstems,water wells, ponds) <br /> Unique Site Features:Recharge Area, Coarse Soil(coarse sands, None At Least One More Than One <br /> gravels),nearby wells <br /> Column Totals Total Points + 1 + _ <br /> Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less <br /> Maximum Allowable BTEX B T E X B T E X N/A3 <br /> Levels m 1.01 50 1 50 50 0.3 0.3 1.0 1.0 <br /> Sample Results for TPH: Maximum Gasoline 1,000 100 10 <br /> Allowable TPH <br /> Levels m Diesel 10,000 1,000 100 <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 is­5 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 <br /> 1. Are BTEX or TPH Concentrations>Allowable Levels? es ❑ No 2. If No, Is Site Closure Recommended? E3 Yes 13 No Vlh <br /> Completed By V4 4ra Date Referred to Site Mitigation Unit for Final Actiont <br /> Reviewed By: Concur with Staff Recommendation ❑Yes ❑ No <br /> Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action <br /> EH 23-0080(Rev 11/14/08) <br />