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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITY/TANK INFORMATION DATE: `S' SITE/FACILITY NAME: DC 20.17 _ STATUS CODE: ADDRESS: ( qV I 19tlE CITY: FA# 00 0–2 2 PR# 'Zj`y 1 a% TANK# TANK SIZE: N/A FUEL TYPE: II. GENERAL SITE HISTORY Is Permit Current? x Yes ❑ No Documented Soil/GW Contamination?*'`* ❑ Yes ❑ No Number of Tanks at Facility Age of Tanks(if available) Type of Tank❑Steel ❑Fiberglass ❑Single ❑Dual III. TANK HISTORY Was Tank Tested? L3Yes L3No Failed Testing? ❑ Yes ❑ No If Yes,Provide Dates: Was Tank System Repaired? ❑ Yes ❑ No If Yes,Describe Repair: Was Repair Done Under Permit? ❑Yes ❑ No Were Soil Samples Analyzed? ❑Yes ❑ No ❑ BTEX❑TPH-G❑TPH-D ❑ LEAD ❑EDB❑OTHER Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill ❑ Unknown ❑Other IV. REMOVAL HISTORY Attach File Soil Samples Received? X Yes ❑ No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes ❑ No L3 Irrigation: #L— 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 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 Depth(feet)* >100 51 -100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) 10 None Average Annual Precipitation(14 inches for SJC area) ------- <10 9 10-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migrationr, i.e.septic sstems,water wells,ponds) -------- None / Unknown Present Unique Site Features:Recharge Area,Coarse Soil(coarse sands, None I At Least One More Than One ravels,nearb wells Column Totals Total Points leo + fib + _ Sample Results for BTEX: Range of Total Points 49 Points or More 41–48 Pot 40 Points or Less Maximum Allowable BTEX B I T E X B T E X N/A3 Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 Sample Results for TPH: Maximum Gasoline 1,000 510 100 ;j 10 Allowable TPH Levels m Diesel 10,000 1,000 100 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). t 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. L_ 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 ❑ 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 *Subtract soil sample depth from groundwater depth to determine distance be sample depth and groundwater EH 23-0080(Rev6/4/2007)