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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION ,g DATE: � �4. 2Ca SITEIFACILITY NAME; d -4-S S tO,,C� Gi� 1��G�c TrZ�C�D �''� SSV C' • �Y1 � � STATUS CODE,,, r' ADDRESS: �3Z � �• �v !Q/1 �Tv� �1�J�a-� CITY: S�7 c�c�C_� FA#: DD U � I '� 2 PR#: ('Z�J L � 2'1 TANK # 39 — (�'' �2 �1 � � TANK SIZE: i � (� d � FUEL TYPE: . GENERAL SITE HISTORY Is Permit Current? ❑Yes ❑ No A Documented Soil/GW Contamination?*** ❑ Yes � No Number of Tanks at Facility � Age of Tanks (if available) �(2yZ��;-� Type of Tank ❑Dual ❑Steel t_,VVt ❑Fiberglass ❑Single ('�U C.o l� III. TANK HISTORY of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑Unknown ❑Other Was Tank Tested? ❑Yes�o NA Failed Testing? ❑Yes ❑ No�NA If Yes, Provide Dates: Was Tank System Repaired? ❑Yes�No ❑ NA If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes ❑ No�,NA Were Soil Samples Analyzed? Yes ❑ NoBTEX �'PH-G ❑TPH-D�J�.EAD ❑EDB OTHER VbC�: ❑OXYGENATES Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑Unknown ❑Other IV. REMOVAL HISTORY Attach File) Soil Samples Received? •Yes ❑ No Seasonal High Depth to GW v 2 � ft bgs Year/ Reference S�-nl�i � , � c7 � c=j Onsite andlor Nearby Well(s)? ❑Yes '�No ❑Irrigation: # Distance to Tank ft � Score 10 � Score 9 � ❑Domestic: # Distance to Tank ft points if points if Score 5 points if O O O ❑Public: # Distance to Tank ft R condition is R condition is R condition is met met met V. SITE FEATURE –LEACHING POTENTIAL ANALYSIS E E E Minimum Depth to Groundwater from Soil Sample (feet) >100 51 –100 ,� 25 - 50� Fractures in Subsurface (applies to foothill or mountain areas) I � None Unknown Present Average Annual Precipitation (14 inches for SJCarea) -1------ <10 9 10 – 25 -------- 26 - 40z Man -Made Conduits which Increase Vertical Migration -------- None �' Unknown Present i.e, se tics stems, water wells, onds Unique Site Features: Recharge Area, Coarse Soil (coarse sands, / � None At Least One More Than One ravels nearb wells , Column Totals Total Points � + j � + (� _ •��' Sample Results for BTEX: Range of Total Points 49 Points or More 41– 48 Points 40 Points or Less rv�g / Ico� B N© E T N D Maximum Allowable BTEX B T E X B T X E ✓'� D Levels (ppm) 1.0 50 50 50 0.3 0.3 � 1.0 N/A s x d • �l 3 Sample Results for TPH: Maximum Gasoline 1,000 100 10 3 Allowable TPH ` � Levels m Diesel 10,000 1,000 100 Footnotes: *** f documented soil andlor groundwater contamination is present, do not complete leaching potential analysis (i.e. site is already on the contamination list). •-�'� ' � f 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. �� s evels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. VI. STAFF RECOMMENDATIONI REFERRALI REVIEW 1. Are BTEX or TPH Concentrations > Allowable Levels'. `;Yes�No 2. If No, Is Site Closure Recommended? es ❑ No Completed By: C � � v�,f Date Referred to Site Mitigation Unit for Final Actions Reviewed By: � ,97�G ,., Concur with Staff Recommendation Yes ❑ No Date Closure Letter Mailed L��/ � '�� tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080 (Rev 11/14/08)