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SAN JOAQUIN C4JNTY ENVIRONMENTAL HE TH DEPARTMENT UST WORkSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: 1 6/9/2014 SITE/FACILITY NAME: Loves Country Stores of CA #223 STATUS CODE: ADDRESS: 1553 Colony Road, CITY: I Ripon FA#: 0012659 PR#:0516526 TANK SIZE: 20,000 FUEL TYPE: 4Diesel — A D5j E55j4Q II. GENERAL SITE HISTORY Is Permit Current? ♦ Yes ❑ No ❑ NA Documented Soil/GW Contamination?` ❑ Yes XINO Number of Tanks at Facility 5 Age of Tanks (if available) NA Type of Tank ❑Steel ❑Fiberglass ❑Single *Dual III. TANK HISTORY Was Tank Tested? *Yes ❑No ❑ NA Failed Testing? ❑ Yes ♦ No ❑ NA If Yes, Provide Dates: Was Tank System Repaired? *Yes ❑ No ❑ NA If Yes, Describe Repair: UDC and piping replacement (cI\/I. 9 f juyi,,_ 2-014) Was Repair Done Under Permit? *Yes ❑ No ❑ NA Were Soil Samples Analyzed? ♦ Yes ❑ No * BTEX ❑ TPH-G *TPH-D ❑ LEAD ❑ EDB ❑ OTHER ❑OXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ♦ Unknown ❑ Other IV. REMOVAL HISTORY (Attach File) Soil Samples Received? ♦ Yes ❑ No Seasonal High Depth to GW 20 ft bgs Year/ Reference 1999 Onsite and/or Nearby Well(s)? ❑ Yes ❑ No Ll Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑ Domestic: # Distance to Tank ft 0 points if O points if 0 Score 5 points if LJ Public: # Distance to Tank ft R E condition is met R E condition is met R E condition is met V. SITE FEATURE – LEACHING POTENTIAL ANALYSIS Minimum Depth to Groundwater from Soil Sample (feet) >100 51 –100 0 25-501 Fractures in Subsurface (applies to foothill or mountain areas) 10 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 9 Unknown Present i.e. septics stems, water wells,ponds) Unique Site Features: Recharge Area, Coarse Soil (coarse sands, 10 None At Least One More Than One gravels), nearby wells Column Totals Total Points 20 + 18 + 0 =38 Sample Results for BTEX: Range of Total Points 49 Points or More 41 – 48 Points 40 Points or Less B <0.005 mg/kg T <0.005 mg/kg Maximum Allowable BTEX B T E X B T E X N/A3 E <0.005 mg/kg Levels (ppm) 1.0 50 50 50 0.3 0.3 1.0 1.0 X <0.005 mg/kg Sample Results for TPH: Maximum Gasoline 1,000 100 10 350 mglkg Allowable TPH 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, score 0 points. 3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. VI. STAFF RECOMMENDATION/ REFERRAL/ REVIEW 1. Are BTEX or TPH Concentrations > Allowable Levels? ❑ Yes ♦ No 7 2. If No, Is Site Closure Recommended? ❑ Yes ♦ No Completed By: Qu mot n Date Referred to Site Mitigation Unit for Final Actiont G _ q 'I Reviewed By: �Z�p.Z `� 2y Concur with Staff Recommendation ❑ YesXNo��,��%?' Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080 (Rev 11/14/08)