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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITY/TANK INFORMATION DATE: g-l ` SITE/FACILITY NAME: u��' 356WA STATUS CODE: ADDRESS: 177 IU. 9)9 f (A 93 CITY: I Lqj FA#: PR#: Os3111110 I TANK# 39 ®!'>-2D612 TANK SIZE: I FUEL TYPE: VN t, 2 6� II. GENERAL SITE HISTORY Is Permit Current? Yes ❑ No Documented Soil/GW Contamination?"' ❑ Yes X No Number of Tanks at FacilityUN ►N ❑Du I Age of Tanks(if available) Type f Tank Steel ❑Fiberglass )ISingle f,�d � Ill. TANK HISTORY Was Tank Tested? ❑ Yes X No Failed Testing? ❑ Yes ❑ No If Yes,Provide Dates: Was Tank System Repaired? ❑ Yes No If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes W%o Were Soil Samples Analyzed? `tfYes ❑ No T14 BTEX TPH-G TPH-D A LEAD I)LEDB OTHER Type of Failure/Discharge: ❑Catastrophic ❑ Long-term Leak ❑ Overfill Unknown ❑ Other IV. REMOVAL HISTORY Attach File Soil Samples Received? ❑Yes ❑No 7Seasonal High Depth to GW ft bgs Year/Reference '�P!: Onsite and/or Nearby Well(s)? ❑Yes ❑ No ❑ Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑ Domestic:# Distance to Tank ft 0 points if 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank ft 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) to >100 51 -100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) None 61Unknown Present Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migration None Unknown 5 Present i.e.septics stems,water wells,ponds Unique Site Features: Recharge Area,Coarse Soil(coarse sands, None At Least One More Than One gravels), nearby wells Column Totals Total Points Z- I S (-I 2 ample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less o .d Z�o M Maximum Allowable BTEX B T E X B T E X N/A 3 p Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 Sample Results for TPH: Maximum Gasoline 1,000 100 10 v 2 '� I� Allowable TPH TP P Levels ppm Diesel 10,000 1,000 100 Footnotes: "**If documented soil and/or groundwater contamination is present,do not complete leaching potential analysis i.e. ready on the contamination list). 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 )k No 2. If No, Is Site Closure Recommended? Yes ❑ No Completed By: %j Date Referred to Site Mitigation Unit for Final Action/ Reviewed By: XvfI ion fUn Concur with Staff Recommendation Alrfes ❑ No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)