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SAN JOAQUINr5RUNTY ENVIRONMENTAL HE4 H DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION a y DATE: G 1Q 1 SITE/FACILITY NAME: OS0 PoNeo, P r STATUSCODE: 10 ADDRESS: W, W P44 w b 40,j R K CITY: b'fuG FA#: 'Z 1 PRM 102 3 Z TANK# 39 OZS 6 TANK SIZE: 100l) �1- FUEL TYPE: LVd <t O /Z- II. GENERAL SITE HIS ORY Is Permit Current? ❑ Yes�L No Documented Soil/GW Contamination?— ❑ Yes )T No Number of Tanks at Facility Z Age of Tanks(if available) I �uaf Tank❑Steel ❑Fiberglass ❑Single III. TANK HISTORY Was Tank Tested? g Yes ❑ No Failed Testing? ❑ Yes Qf No If Yes,Provide Dates: Was Tank System Repaired? ❑ Yes jZ No If Yes, Describe Repair: Was Repair Done Under Permit? ❑Yes V No Were Soil Samples Analyzed?` Yes ❑ NO ETEX❑TPH-G 21 TPH-D WVLEAD ❑EDB❑OTHER Type of Failure/Discharge: ❑ Catastrophic ❑Long-term Leak ❑ Overfill ❑ Unknown ❑Other IV. REMOVAL HISTORY Attach File Soil Samples Received?)Q Yes ❑No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes ❑ No ❑ Irrigation: # Distance to Tank ft C Score 10 C Score 9 C ❑ Domestic:# Distance to Tank ft O points if 0 points if 0 Score 5 points if ❑Public: # Distance to Tank ft R condition is R condition is R condition is met V. SITE FEATURE–LEACHING POTENTIAL ANALYSIS E met E met E Minimum Depth to Groundwater from Soil Sample(feet) >100 51 -100 25-501 Fractures in Subsurface(applies to foothill or mountain areas) None Average Annual Precipitation(14 inches for SJC area) -------- <10 9 W-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migration None Unknown Present .e.septic sstems,water wells, ponds) Unique Site Features: Recharge Area, Coarse Sail(coarse sands, None At Least One More Than One gravels), nearb wells Column Totals Total Points + + _ Sample Results for BTEX: Range of Total Points 49 Points or More 41 –48 Points 40 Points or Less N }, Maximum Allowable BTEX B TE X B T E X N/A3 Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 Sample Results for TPH: Maximum Gasoline 1,000 100 10 (� Allowable TPH 1.J Levels m Diesel 10,000 11000 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 am 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?AYes o 2. If No, Is Site Closure Recommended?XYes O No Completed By: Date Referred to Site Mitigation Unit for Final Actionr Reviewed By: Concur with Staff Recommendation Yes o Date Closure Letter Mailed TAll Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev6/42007)