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d SAN JOAQUIN COUNTY ENVIRONMEN a AL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITYITANK INFORMATION DATE: � � c SITE/FACILITY NAME: fg,; ,; ;I - { ' A / <. STATUS CODE: J ADDRESS: relf 6A � P f� { , CITY: Taitt, FA#: PR#: TANK # 39 TANK SIZE: �Q ; G FUEL TYPE: 1 G ; t , y II. GENERAL SITE HISTORY L w Is Permit Current? El Yes El No CI 6, } Documented Soil/GW Contamination?` ❑ Yes El No N/' evil (J Number of Tanks at Facility Age of Tanks (if available) W''FqLz M I � Type 0f TankI45teel ❑Fiberglass Single tTa N ❑Dual III. TANK HISTORY Was Tank Tested? ❑ Yes ❑ No Failed Testing? ❑ Yes ❑ No If Yes, Provide Dates: NRLC M (.,tA co (�irj owN) Was Tank System Repaired? ❑ Yes ❑ No If Yes, Describe Repair: _[ Lre Mj A ( . pi (�NO v ) N Was Repair Done Under Permit? 11 Yes C3 No Were Soil Samples Analyzed? W Yes El No BTEXv TPH-G O TPH-D LEAD LG y ❑ EDB CTHERQXI 1 Type of Failure/Discharge: ❑ Catastrophic ❑ Long-term Leak ❑ Overfill $Unknown ❑ Other IV, REMOVAL HISTORY (Attach File) Soil Samples Received? ft".0es ❑ No Seasonal High Depth to GW Year/ Reference ( 1 J �OCJ!P.00 Onsite and/or Nearby Wallis)? ❑ Yes ❑ No ❑ Irrigation: # Distance to Tank ft Score 10 C Scare 9 C Jd"Domestic: #�_ Distance to Tan tm ft 0 points if 0 points if 0 Score 5 points if ❑ Public: # Distance to Tank It 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) L 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 UnknownPresent .e. septic systems, 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 () + + J Sample Results for BTEX: Range of Total Points 49 Points or More I 41 — 48 Points 40 Points or Less Maximum Allowable BTEX B T E X B T E X I N/A3 Levels ppm 1 .0 50 50 50 0.3 0.3 1 .0 1 .� Sample Results for TPH : Maximum Gasoline 12000 I 100 ` 10 Allowable TPH Levels ppm Diesel 10,000 1 ,000 100 Footnotes: *** It documented soil and/or groundwater contamination is present, do not complete leaching potential analyw 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 GTS - i_ 7, C,jq 111 _ In ! r. ' 0; ( a r- _10) 1 . Are BTEX or TPH Concentrati4s > Allowable Levels? ;P Yes LJ 2. If No, Is Site Closure Recomr nded? ❑ Yes ❑ No Completed By: C_111 Al j Date Referred to Site Mitigation Unit for Final Actiont ` _ Reviewed By: ) - Concur with Staff Recommendation ❑ Yes ❑ No tAII Cases are Referred to Site Mitigation for Final Action Date Closure Letter Mailed EH 23-0080 (Rev 11/14/08)