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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. FACILITYITANK INFORMATION ?� DATE: <br /> SITE/FACILITY NAME: TR(}� 04c", a01 ;5q STATUS CODE: <br /> ADDRESS: 2 'f# 157ke -r- CITY: ?Y� <br /> FA# 0C' I 22 PR#0 .qr!?78Y01 TANK# <br /> TANK SIZE: N/A FUEL TYPE: <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? X Yes ❑ No Documented Soil/GW Contamination?*** ❑ Yes ❑ No <br /> Number of Tanks at Facility Age of Tanks(if available) Type of Tank❑Steel ❑Fiberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑ Yes ❑ No Failed Testing? ❑ Yes ❑ No If Yes,Provide Dates: <br /> Was Tank System Repaired? ❑ Yes ❑ No If Yes, Describe Repair: <br /> Was Repair Done Under Permit? ❑Yes ❑ No Were Soil Samples Analyzed? ❑Yes ❑ No ❑ BTEX❑TPH-G❑TPH-D ❑LEAD <br /> PLJ EDB❑OTHER <br /> Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑ Overfill ❑ Unknown ❑Other <br /> IV. REMOVAL HISTORY Attach File) <br /> Soil Samples Received? X Yes ❑ No Seasonal High Depth to GW ft bgs Year/Reference <br /> Onsite and/or Nearby Well(s)? ❑Yes ❑ No <br /> C3 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 /> ❑ 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 Depth(feet)* >100 51-100 S 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) 10 None <br /> Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 <br /> Man-Made Conduits which Increase Vertical Migration None Unknown Present <br /> i.e.septic sstems,water wells,ponds) <br /> Unique Site Features:Recharge Area,Coarse Soil(coarse sands, t O None At Least One More Than One <br /> ravels),nearbywells <br /> Column Totals Total Points 17-0 + /U + - <br /> Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 3 40 Points or Less <br /> Maximum Allowable BTEX B T E X B E I X N/A3 <br /> Levels m 1.0 50 1 50 50 0.3 0.3 1.0 1.0 <br /> Sample Results for TPH: Maximum Gasoline 1,000 1�yuo 100 10 <br /> Allowable TPH <br /> Levels m Diesel 10,000 724tx:) 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 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 <br /> 1. Are BTEX or TPH Concentrations>Allowable Levels? ❑Yes ❑ No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No <br /> Completed By: Date Referred to Site Mitigation Unit for Final Actiont <br /> Reviewed By Concur with Staff Recommendation ❑Yes ❑ No <br /> Date Closure Letter Mailed tAII Cases are Referred to Site Mitigation for Final Action <br /> *Subtract soil sample depth from groundwater depth to determine distance be sample depth and groundwater <br /> EH 23-0080(Rev6/4/2007) <br />