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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITY/TANK INFORMATION DATE: 04/20/2018 SITE/FACILITY NAME: Country Marketplace STATUS CODE: ADDRESS: 1789 W.Charter Way CITY: Stockton FA#: FA0007486 PR#: PRO506538 TANK# 39 TANK SIZE: FUEL TYPE: Gasoline II. GENERAL SITE HISTORY Is Permit Current? ❑ Yes 0 No ❑ NA Documented Soil/GW Contamination?*** ❑ Yes ❑ No Number of Tanks at Facility 2 Age of Tanks(if available) 11 years Type of Tank❑D Steel ❑Fiberglass ❑Single ❑Dual III. TANK HISTORY Was Tank Tested? ❑Yes ❑No ONA Failed Testing? ❑Yes ❑ No 0 NA If Yes, Provide Dates: Was Tank System Repaired? ❑Yes ❑ No 0 NA If Yes, Describe Repair: Was Repair Done Under Permit? ❑x Yes❑ No LINA Were Soil Samples Analyzed? 0 Yes ❑ No IZI BTEX IZI TPH-G❑TPH-D ❑x LEAD❑x EDB ❑OTHER ❑x OXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown ❑ Other IV. REMOVAL HISTORY(Attach File) Soil Samples Received? I]Yes ❑ No Seasonal High Depth to GW 20 ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes I] No LJ Irrigation: # Distance to Tank ft � Score 10 C Score 9 C ❑ Domestic:# Distance to Tank ft0 points if O points if 0 Score 5 points if Ll 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 0 25-501 Fractures in Subsurface(applies to foothill or mountain areas) None 9 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.septic systems,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 10 + 27 + 0 =37 Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less B=ND E T= ND Maximum Allowable BTEX B T E X B T X 3 E=ND Levels(ppm) 1.0 50 50 50 0.3 0.3 0 1.0 NIA X=ND Sample Results for TPH: Maximum Gasoline 1,000 100 10 ND Allowable TPH Levels ppm 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? ❑x Yes ❑ No 2. If No, Is Site Closure Recommended? ❑Yes ❑ No Completed By:Cesar Ruvalcaba Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation ❑Yes ❑ No Date Closure Letter Mailed tAII Cases are Referred to Site Mitigation for Final Action EH 23-0080(Rev 11/14/08)