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SAN JOAQUIN CITY ENVIRONMENTAL HEAL WH DEPARTMENT <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION <br />I. FACILITY/TANKINFORMATION DATE: In SIJ <br />SITEIFACILITY NAME: j Q I c Q QJf t L n• STATUS COD : �� <br />PR# <br />TANK SIZE: f 50 I N/A I FUEL TYPE: <br />Is Permit Current? x Yes No Documented Soil/GW Contamination?"' ❑ Yes A No <br />Type of Tank teel ❑Fibergl ss ❑Single <br />Number of Tanks at Facility $ Age of Tanks (if available) u- k ❑Dual <br />11 TAk1V WCTn0V iwl /M^11IM. <br />Was Tank Tested? ❑ Yes d No <br />Failed Testing? ❑ Yes No <br />If Yes, Provide Dates: <br />Was Tank System Repaired? ❑ Yes No <br />If Yes, Describe Repair: <br />Repair Done Under Permit? L3 Yes ❑ NWA <br />Were Soil Samples Analyzed? L3 Yes L3 No <br />L3 TWas <br />❑BEDB L3OTHE ❑TPH- ❑LEAD <br />Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill Unknown ❑ Other <br />nl DCIIM/AI UlMnDV /AH��h Filet <br />Soil Samples Received x Ye ❑ No <br />Seasonal High Depth to GW ft bgs <br />Yearl Reference <br />Onsite and/or Nearby Well(s)? Yes ❑ No <br />Irrigation: # a Distance to Tank ioO ft <br />❑ Domestic: # Distance to Tank _ It <br />❑ Public: # Distance to Tank _ ft <br />C <br />0 <br />R <br />E <br />Score 10 <br />points if <br />condition is <br />met <br />C <br />0 <br />R <br />E <br />Score 9 <br />points if <br />condition is <br />met <br />C <br />0 <br />R <br />E <br />Score 5 points if <br />condition is met <br />V. SITE FEATURE – LEACHING POTENTIAL ANALYSIS <br />Minimum Depth to Groundwater from Soil Sample Depth (feet)' <br />>100 <br />51-100 <br />Q <br />25-501 <br />Fractures in Subsurface (applies to foothill or mountain areas) <br />None <br />Average Annual Precipitation (14 inches for SJC area) <br />---- <br /><10 <br />9 <br />10-25 <br />--- <br />26-402 <br />Man -Made Conduits which Increase Vertical Migration <br />i.e. septic sstems, water wells,ponds) <br />—_ <br />None <br />Unknown <br />Present <br />Unique Site Features: Recharge Area, Coarse Soil (coarse sands, <br />ravels , nearb wells <br />I D <br />None <br />At Least One <br />More Than One <br />Column Totals Total Points <br />p <br />* <br />g <br />* <br />Sample Results for BTEX: <br />Nn C 0,00S' �P, , <br />Range of Total Points <br />49 Points or More <br />41-48 Points <br />40 f loints or Less <br />Maximum Allowable BTEX <br />Levels m <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 <br />NIA s <br />Sample Results for TPH: <br />Nei G <br />Maximum <br />Allowable TPH <br />Levels m <br />Gasoline <br />1,000 <br />100 <br />10 <br />Diesel <br />10,000 <br />1,000 <br />100 <br />Footnotes: `" If documented soil andforgroundwater contamination is present, do not complete leaching potential analysis (i.e. site is already on the centaminabon f Q. <br />I If depth is >5 feet and < 25 feet, score 0 points. If depth is <=5 feet, do not use table. Y If precipitation is > 40 inches, score 0 points. <br />9 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH-Gasoline or 100 ppm forTPH-Diesel. <br />VI. STAFF RECOMMENDATION/ REFERRALI REVIEW <br />1. Are BTEX or TPH Concentrations > Allowable Levels? ❑ Yes ❑ No <br />2. If No, Is Site Closure Recommended? ❑ Yes No <br />Completed By: <br />Date Referred to Site Mitigation Unit for Final Actions <br />Reviewed By: <br />Concur with Staff Recommendation ❑ Yes ❑ 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 (Rev6/42007) <br />