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SAN JOAQUIN«UNTY ENVIRONMENTAL HR&TH DEPARTMENT <br /> UST WORKSHEET FOR SITE CLOSURE IVALUATION <br /> I. FACILITY/TANK INFORMATION DATE: <br /> SITE/FACILITY NAME: STATUS CODE: <br /> ADDRESS: '�3 t✓ St CITY: <br /> FA#: Q o o -- �S PR#: U C-2 Ue-f o I TANK# 39 d 2 0.7 t�D 2 <br /> TANK SIZE: 3LD C() 4 Q FUEL TYPE: i L.VI( 4f Ow n <br /> II. GENERAL SITE HISTORY <br /> Is Permit Current? LJ Yes ❑ No'*A Documented Soil/GW Contamination?**` ❑ Yes 11A No <br /> Number of Tanks at Facility Age of Tanks(if available) C._o �n C)Wr) Type of Tank❑Steel iberglass ❑Single <br /> ❑Dual <br /> III. TANK HISTORY <br /> Was Tank Tested? ❑Yes*o LINA Failed Testing? C3 Yes Ll No ANA If Yes, Provide Dates: [� A <br /> Was Tank System Repaired?❑Yes ❑ No`�NA I If Yes, Describe Repair: <br /> BTEX TPH-G , PH-D LEAD❑EDB <br /> Was Repair Done Under Permit? ❑Yes❑ No'(NA Were Soil Samples Analyzed? C,Yes ❑ No OTHER 0' GENATES <br /> Type of Failure/Discharge: ❑Catastrophic ❑ Long-term Leak ❑Overfill Xunknown ❑Other <br /> IV. REMOVAL HISTORY Attach File <br /> Soil Samples Received?XYes ❑No Seasonal High Depth to GW 3 O�ft bgs Year/Reference al <br /> Onsite and/or Nearby Well(s)? ❑Yes)No <br /> ❑ Irrigation: # Distance to Tank ft � Score 10 C Score 9 C <br /> ❑ Domestic:# Distance to Tank ft0 points if O points if 0 Score 5 points if <br /> LJ 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(feet) >100 51 -100 1j 25-501 <br /> Fractures in Subsurface(applies to foothill or mountain areas) None Unknown Present <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 /> Uni ue Site Features: Recharge Area,Coarse Soil(coarse sands, None At Least One More Than One <br /> ravels nearby wells <br /> Column Totals Total Points + 2"l + _ Z <br /> Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less <br /> B N,U <br /> T Maximum Allowable BTEX B T E X B T E X N/A3 <br /> E Levels(ppm) 1.0 50 50 50 0.3 0.3 1.0 1.0 <br /> X <br /> Sample Results for TPH: Maximum Gasoline 1,000 100 10 <br /> r N D -,D 2, S- Allowable TPH Levels m Diesel 10,000 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 is­5 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. f No, Is Site Closure Recommended? ❑Yes ❑ No <br /> Completed By,_5�-Z{C Date Referred to Si itigation Unit for Final Actions <br /> Reviewed By: Concur with St Recommendation ❑Yes ❑ No <br /> Date Closure Letter Mailed 1AII Cases are eferred to Site Mitigation for Final Action <br /> N)tq <br /> EH 23-0080(Rev 11/14/08) <br />