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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I . FACILITYITANK INFORMATION DATE : 1:11: uZ / 1 SITE/FACILITY NAME : BL �� STATUS CODE : ADDRESS : 6 � S Sacra lmg^r Ilv <S'r CITY: L4j C6 FA#: 0 0 PR#: OSg4 9 TANK # 39 t) oZ Q Fj16 4 TANK SIZE : 13 ti/ ( u tiJ FUEL TYPE : U p 44vi II . GENERAL SITE HISTORY Is Permit Current? J Yes ❑ No ❑ NA Documented Soil/GW Contamination ?` ❑ Yes 9"� No Number of Tanks at Facility Age of Tanks (if available) Type of Tank WSteel ❑ Fiberglass ❑ Single ❑ Dual III . TANK HISTORY Was Tank Tested ? ❑Yes No ❑ NA Failed Testing ? ❑ Yes ❑ No Cp NA If Yes , Provide Dates : MIA Was Tank System Repaired? ❑ Yes LA No ❑ NA If Yes , Describe Repair: rJ , A Was Repair Done Under Permit? ❑ Yes LJ No d NA Were Soil Samples Analyzed? I /Yes LJ No BTEX TPH-G TPH-D LEAD LI EDB ❑ OTHER ❑ OXYGENATES Type of Failure/Discharge : ❑ Catastrophic ❑ Long-term Leak ❑ Overfill l2f Unknown ❑ Other IV, REMOVAL HISTORY Attach File _ Soil Samples Received? 4( Yes L3 No Seasonal High Depth to GW 7 0 ft bgs Year/ Reference Onsite and/or Nearby Well (s) ? dyes " t No LI Irrigation : # Distance to Tank ' ft � Score 10 C Score 9 � ❑ Domestic: # Distance to Tank ft 0 points if 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank 1500ft 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) > 100 51 — 100 25 - 501 Fractures in Subsurface (applies to foothill or mountain areas) , None Unknown Present 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 , I None At Least One More Than One gravels) , nearby wells _ j Column Totals Total Points � � + t Ol + = rte' Sample Results for BTEX: Range of Total Points 49 Points or More 41 — 48 Points 40 Points or Less B O T Maximum Allowable BTEX B T E X B T 1 X N/A3 E 0 Levels (ppm) 1 . 0 50 50 50 0 . 3 0 . 3 0 1 . 0 X Sample Results for TPH : Maximum Gasoline 13000 100 10 Allowable TPH Levels m Diesel 10 , 000 11000 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 is <=5 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 to No 2 . If No, Is Site Closure Recommended ? & Yes ❑ No Completed By : Date Referred to Site Mitigation Unit for Final Actiont 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 (Rev 11 / 14/08)