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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION 1, FACILITYITANK INFORMA13ION DATE: SITE/FACILITY NAME: f I { / LekSTATUS CODE: r ADDRESS: i PR#: (� TANK # FA#: dd TANK SIZE: �U' u� FUEL TYPE: , II, GENERAL SITE HISTORY t Is Permit Current? ❑ Yes ❑ No C. vl �p ;�, Documented Soil/GW Contamination?*** ❑ Yes ❑ No` l ' at�{rNL);vJU Number of Tanks at Facility Age of Tanks (if available) ( Lt l t t Type of Tank tee[ ❑Fiberg assingle ( (NIJ(� JAJ ❑ Dual III. TANK HISTORY Was Tank Tested? ❑ Yes C] No Failed Testing? LJ Yes ❑ No If Yes, Provide Dates: '�iL� joL(.i� L�NNLtNh1 Was Tank System Repaired? ❑ Yes ❑ No If Yes, Describe Repair: Pt a MIA - awl;�jW/\4 N JBTEX JTPH-G LJTPH-0 LEAD Was Repair Done Under Permit? ❑ Yes ❑ No Were Soil Samples Analyzed? `f[Yes ❑ No ❑ EDB krpTHERI t N e Type of Failure/Discharge: L3Catastrophic Ll Long-term Leak El Overfill known ❑ Other IV, REMOVAL HISTORY (Attach File) Soil Samples Received , Yes ❑ No Seasonal High Depth to GW ' V Ngs Year/ Reference Onsite and/or Nearby Well(s)? ❑ Yes ❑ No Ll Irrigation: # Distance to Tank ft Score 10 C Score 9 Domestic: # t Distance to Tank 11 ft 0 points if O points if O 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 G 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. se tic s 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 + �� + Sample Results for BTEX: Range of Total Points 49 Points or More 41 — 48 Points 40 Points or Less `)6q(qDM 3 ] '6PP ^A Maximum Allowable BTEX B T E X B T E X N/A3 Levels ppm 1 .0 50 50 50 0.3 G.3 1 ,0 1 .0 Samplle�ResulltssforTPH: low Maximum Gasoline 13000 100 10 6µi l 1� � AlLev ebleT�H Diesel 10,000 1 ,000 t 100 Footnotes: *** If documented soll andlor 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 forTPH—Gasollneor 100 ppm forTPH-Diesel. VI. STAFF RECOMMENDATION/ REFERRAL/ REVIEW 1 , Are BTEX or TPH Concentrations > Allowable Levels?' Yes ❑ No 2. If No, Is Site Closure Recommended? ❑ Yes o Completed By: Date Referred to Site Mitigation Unit for Final Actiont r. Reviewed By: X Concur with Staff Recommendation f(Yes ❑ No U4 tAll Cases are Referred to Site Mitigation for Final Action Date Closure Letter Mailed Eff 23-0080 (Rev 11/14/08)