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SAN JOAQUIN C( NTY ENVIRONMENTAL HEAINH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: SITE/FACILITY NAME: I AQ4STATUS CODE: ADDRESS: J CITY: FA#: ?,0 PR#: TANK# 39 TANK SIZE: t3 �14 1 L FUEL TYPE: Memium II. GENERAL SITE HISTO Is Permit Current? Yes ❑ No ❑ NA Documented Soil/GW Contamination?*** ❑ Yes No Number of Tanks at Facility oZ Age of Tanks(if available) Type of Tank❑Steel *iberglass ❑Single &170 tZ Dual III. TANK HISTORY Was Tank Tested? 4Yes ❑No ❑ NA Failed Testing? ❑Yes *No ❑ NA If Yes, Provide Dates: Was Tank System Repaired?❑YesxNo❑ NA If Yes, Describe Repair: Was Repair Done Under Permit?❑Yes L3 No�NA Were Soil Samples Analyzed? XYes EJ No BTEX TPH-G TPH-D LJ LEAD❑ EDB ❑ OTHER ❑OXYGENATES Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown Other IV. REMOVAL HISTORY(Attach File) Soil Samples Received? Yes Ll No Seasonal High Depth to GW _ft bgs Year/Reference 'A Onsite and/or Nearby Well(s)? ❑Yes *No S S S ❑ Irrigation: # Distance to Tank ft C Score 10 C Score 9 C ❑ Domestic:# Distance to Tank ftO points if O points if O Score 5 points if L3 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 S 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.septics stems,water wells, ponds Unique Site Features: Recharge Area, Coarse Soil(coarse sands, None At Least One More Than One gravels), nearby wells Column Totals Total Points U + + C = / Z Sample Results for BTEX: Range of Total Points 49 Points or More 41 —48 Points 40 Points or Less B rol - 4 - (,Zt31 T N,6q bo-e_4- Maximum Allowable BTEX B T E X B T E X 3 E Levels(ppm) 1.0 50 50 50 0.3 0.3 1.0 1.0 NIA X Sample Results for TPH: Maximum Gasoline 1,000 100 10 Turek- P-+ — (,z,3rLf 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? es o 2. If No, Is Site Closure Recommen ed? Yes ❑ No Completed By: Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation ❑Yes ❑ No Date Closure Lette Mailed tAll Cases are Referred to Site Mitigation for Final Action Ell 23-0080(Rev 11/14/08)