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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION 1. FACILITYITANK INFORMATION DATE: I May 8, 2017 SITEIFACILITY NAME: I Single Facility Residence STATUS CODE: ADDRESS: 8476 E Kettleman Lane, Lodi, CA 95240 CITY: Lodi FA#: FA0023769 PR#:PR0541462 TANK #139- TA0520816 TANK SIZE: 350 FUEL TYPE: gasoline II_ GENERAL SITE HISTORY Is Permit Current? ❑ Yes ❑ No 0 NA Documented Soil/GW Contamination?" ❑ Yes `X) No Number of Tanks at Facility 17 Age of Tanks (if available) 40 years (approx.) Type of Tank ASteel ❑Fiberglass Single ❑Dual III. I ANK MIU I UKY Was Tank Tested? ❑Yes 4No ❑ NA Failed Testing? ❑ Yes ❑ No 4 NA If Yes, Provide Dates: Was Tank System Repaired? ❑Yes ❑ No NA I If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes R No 17 NA Were Sal Samples Analyzed?Yes ❑ NoI BTEXXTPH-G L3TPH-D J4 LEAD EJ EDB OTHER ❑OXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill XUnknown ❑ Other ■Lo■:aiL911►_1MiIN 101:4M 1WT44A21ra Soil Samples Received? Yes ❑ No Seasonal High Depth to GW _I 3,0 ft bgs Year/ Reference Z� Onsite and/or Nearby Well(s)? ❑ Yes ❑ No LJ Irrigation: # Distance to Tank ft C Score 10 C Score 9 C _>d)omestic: #--L- Distance to Tank -7-0 ft 0 points if 0 points if Score 5 points if ❑ Public: # Distance to Tank ft R E condition is met R E condition is met 0 R E condition is met V. SITE FEATURE - LEACHING POTENTIAL ANALYSIS Minimum Depth to Groundwater from Soil Sample (feet) (Q >100 51 -100 25-501 Fractures in Subsurface (applies to foothill or mountain areas) (0 None Unknown Present Average Annual Precipitation (14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 Man -Made Conduits which Increase Vertical Migration None Unknown Present i.e. septic sstems, water wells,ponds) Unique Site Features Recharge Area, Coarse Soil (coarse sands, r None At Least One More Than One ravels, nearby wells l� Column Totals Total Points�J + + _ 3iJ Sample Results for BTEX: Range of Total Points 49 Points or More 41- 48 Points 40 Points or Less B E T �� Maximum Allowable BTEX Levels B 1.0 T 50 E 50 X 50 B 0.3 T 0.3 X 1.0 N/A3 (ppm) 0 X Sample Results for TPH: Maximum Gasoline 1,000 100 10 Allowable TPH tV 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). 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, sure 0 points. 3 Levels for BTEX are not applicable at a concentration of 10 pprn 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? A Yes ❑ No Completed By: �/-Z.r 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 EH 23-0080 (Rev 11114/08)