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SAN JOAQUIN C( NTY ENVIRONMENTAL HEA, H DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION DATE: -1 ' I. FACILITYITANK INFORMATION STATUS CODE: SITE/FACILITY NAME: ADDRESS: e(_Shin LX- CITY: S�a�K FAM F PRPR* O -I 5 TANK# 39 �D FA TANK SIZE: �JFJO Ion FUEL TYPE: O 1 II. GENERAL SITE HISTORY Is Permit Current? at Yes ❑ No ❑ NA Documented Soil/GW Contamination?"' ❑ Yes' No Type of Tank❑Steel (Fiberglass ❑Single Number of Tanks at Facility Age of Tanks(if available) pe III. TANK HISTORY Was Tank Tested? 691'es ❑No ❑NA Failed Testing? ❑Yes 16 No ❑NA If Yes,Provide Dates: Was Tank System Repaired?❑Yes No❑NA If Yes,Describe Repair: ❑BTEX❑TPH-G❑TPH-D ❑LEAD❑EDB Was Repair Done Under Permit?❑Yes❑ No 0 NA Were Soil Samples Analyzed? ❑Yes No ❑OTHER OX Type of Failure/Discharge: ❑Catastrophic ❑Long-term Leak ❑Overfill q1 Unknown ❑Other IV. REMOVAL HISTORY Attach File Soil Samples Received? es ❑No Seasonal High Depth to GW j�ft bgs Year/Reference q Onsite and/or Nearby Well(s)? L3 Yes No S S S ❑ Irrigation: # Distance o Tank_ It C Score 10 C Score 9 ❑Domestic:# Distance to Tank_ ft 0 points if 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank_ tt condition is condition is R condition is met E met E met E V. SITE FEATURE-LEACHING POTENTIAL ANALYSIS Minimum Depth to Groundwater from Soil Sample(feet) >100 51-100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) 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, None At Least One More Than One ravels), nearbywells Column Totals Total Points 'd o + + � = 3y Sample Results for BTEX: Range of Total Points 49 Points or More 41 -48 Points 40 Points or Less B T Maximum Allowable BTEX B T E X B T E XN/A3 E Levels(ppm) 1.0 50 50 50 0.3 0.3 0 1.0 x P,.3 4 -sao—. -.I Sample Results for TPH: Maximum Gasoline 1,000 100 10 N� 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 forTPH-Diesel. VI. STAFF RECOMMENDATION/REFERRAL/REVIEW 1. Are BTEX or TPH Concentrations>Allowable Levels? QYes No 2. If No,Is Site Closure Recommended? iff Yes ❑ No Completed By: Date Referred to Site Mitigation Unit for incl Actiont Lµ- Z(4 — IT Reviewed By: .r, Concur with Staff Recommendation 16 Yes ❑ No Date Closure Letter Mailed tAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)