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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION <br />I. FACILITY/TANK INFORMATION <br /> DATE: <br />STATUS CODE: fr.Atf 6 vr,;m SITE/FACILITY NAME: <br />TANK # for c 740 ,0 <br />ADDRESS: <br />FA# <br />TANK SIZE: <br />4 <br />f-100 <br />-toe) 2-18 7C' PR# <br />N/A <br /> FUEL TYPE: <br />CITY: 'S 7 oe'47z24.41 <br />••• •••••••m• sa •., •w• • .... ... ... ...... V* <br />Is Permit Current? x Yes CI No Documented Soil/GW Contamination?' CI Yes 0 No <br />Number of Tanks at Facility <br />., <br />Age of Tanks (if available) <br />Type of Tank 0Steel CIFiberglass OSingle <br />CIDual <br />Was Tank Tested? 0 Yes 0 No Failed Testing? CI Yes 0 No If Yes, Provide Dates: <br />Was Tank System Repaired? CI Yes 0 No If Yes, Describe Repair: <br />Was Repair Done Under Permit? 0 Yes 0 No Were Soil Samples Analyzed? 0 Yes 0 No CI BTEX 0 TPH-G 0 TPH -D U LEAD <br />0 EDB 0 OTHER <br />Type of Failure/Discharge: 0 Catastrophic CI Long-term Leak 0 Overfill 0 Unknown 0 Other <br />, <br />Soil Samples Received? x Yes 0 No Seasonal High Depth to GW ft bgs Year/ Reference <br />Onsite and/or Nearby Well(s)? 0 Yes 0 No <br />0 Irrigation: # Distance to Tank ft S Score 10 S <br />C Score 9 S <br />C <br />CI Domestic: # Distance to Tank ft C points if 0 points if 0 Score 5 points if <br />0 Public: # Distance to Tank ft 0 condition is R condition is R condition is met <br />R met met <br />V. SITE FEATURE — LEACHING POTENTIAL ANALYSIS E E E <br />Minimum Depth to Groundwater from Soil Sample Depth (feet)* >100 (...----,. 51 — 100 501 <br />Fractures in Subsurface (applies to foothill or mountain areas) , None <br />Average Annual Precipitation (14 inches for SJC area) <10 9 10 — 25 402 <br />Man-Made Conduits which Increase Vertical Migration <br />(i.e. septic systems, water wells, ponds) <br />None Unknown Present <br />Unique Site Features: Recharge Area, Coarse Soil (coarse sands, <br />gravels), nearby wells (C., None At Least One More Than One <br />Column Totals Total Points 9,1„) + + , ;, <br />Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less <br />Maximum Allowable BTEX <br />Levels (ppm) <br />B <br />1.0 <br />T <br />50 <br />E <br />50 <br />X <br />50 <br />B <br />0.3 <br />T <br />0.3 <br />E <br />1.0 <br />X <br />1.0 N/A3 <br />Sample Results for TPH: Maximum Gasoline 1,000 100 k 10 <br />Allowable TPH <br />Levels (ppm) Diesel 10,000 1,000 o'a 100 <br />Footnotes: *** If documented soil and/or groundwater contamination is present, do not complete leaching potential ana <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 <br />3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. <br />ysis (i.e. site is already on the contamination list). <br />is >40 inches, score 0 points. <br />VI. STAFF RECOMMENDATION/ REFERRAL/ REVIEW <br />1. Are BTEX or TPH Concentrations > Allowable Levels? p Yes CI No 2. If No, Is Site Closure Recommended? CI Yes 0 No <br />Completed By: J, q€111-4vvIrt Date Referred to Site Mitigation Unit for Final Actiont <br />Reviewed By: Concur with Staff Recommendation CI Yes 0 No <br />Date Closure Letter Mailed <br />tAll 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)