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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION <br />FACILITY/TANK INFORMATION / <br />SITE/FACILITY NAME: STATUS CODE: <br />ADDRESS: <br />FA#: <br />TANK SIZE: FUEL TYPE: <br />GENERAL SITE HISTORY <br />Is Permit Current? Yes 0 No KNA Documented Soil/GW Contamination?' U YeseNo <br />Number of Tanks at Facility /MI Age of Tanks (if available) Type of Tank 0Steel iberglass OSingle <br />, Dual <br />TANK HISTORY <br /> A . . <br />Was Tank Tested? UYes 0No 0 NA Failed Testing? 0 Yes 0 No 0 NA If Yes, Provide Dates: <br />Was Tank System Repaired? UYes 0 No 0 NA If Yes, Describe Repair: UDC and piping replacement <br />Was Repair Done Under Permit? UYes 0 No 0 NA Were Soil Samples Analyzed? 0 Yes 0 No 0 BTEX CI TPH-G OTPH-D 0 LEAD CI EDB <br />LI OTHER 00XYGENATES <br />Type of Failure/Discharge: 0 Catastrophic 0 Long-term Leak LI Overfill 0 Unknown 0 Other <br />REMOVAL HISTORY Attach File <br />Soil Samples Received? XYes 0 No Seasonal High Depth to GW ED ft bgs Year/ Reference 1999 <br />Onsite and/or Nearby Well(s)? 0 Yes o <br />0 Irrigation: # Distance to Tank ft S Score 10 S <br />C Score 9 S <br />C <br />0 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 R met met SITE FEATURE - LEACHING POTENTIAL ANALYSIS E E E <br />Minimum Depth to Groundwater from Soil Sample (feet) 0 >100 0 51 -100 0 25- 501 <br />Fractures in Subsurface (applies to foothill or mountain areas) 0 None Unknown — Present <br />Average Annual Precipitation (14 inches for SJC area) <10 1 10 - 25 , 26 - 402 <br />Man-Made Conduits which Increase Vertical Migration <br />(i.e. septic systems, water wells, ponds) ------ None Unknown •••11, Present <br />Unique Site Features: Recharge Area, Coarse Soil (coarse sands, <br />gravels), nearby wells <br />v3 None .......- At Least One -. More Than One <br />Column Totals Total Points <br />I 0 a.1/44 6 <br />Sample Results for BTEX: <br />B <0.005 mg/kg <br />T <0.005 mg/kg <br />E <0.005 mg/kg <br />X <0.005 mg/kg <br />Range of Total Points 49 Points or More 41 -48 Points -Points (40or Les) <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 <br />"„I -TPti-ii In-s 5.51 (- / Allowable TPH <br /> <br />t-rvvo 2- q 4..(1 lug _ Levels (ppm) <br />c?) <br />Gasoline 1,000 100 10 <br />Diesel 10,000 1,000 100 <br />Footnotes: *** If documented soirei or groundwater contamination is present, do not complete leaching potential ana ysis (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 />STAFF RECOMMENDATION! REFERRAL/ REVIEW <br />1. Are BTEX or TPH Concentrations > Allowable Levels? LI Yes No 2. If No, Is Site Closure Recommended?KYes 0 No <br />Completed By: E .metAuto Date Referred to Site Mitigation Unit for Final Actiont AffiC <br />Reviewed By: ,4y.4. Concur Concur with Staff Recommendation 0 Yes 0 No ,n Date Closure Letter Mailed , v tAll Cases are Referred to Site Mitigation for Final Action <br />EH 23-0080 (Rev 11/14/08) ke.t.0 40u3S I