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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I. FACILITY/TANK INFORMATION DATE: 2 ` SITE/FACILITY NAME: l.t 1 S+0 P STATUS CODE: ADDRESS: 6' rely CITY: FA#: PR#: TANK#j 39 TANK SIZE: FUEL TYPE: II. GENERAL SITE HISTORY Is Permit Current? Yes ❑ No Documented Soil/GW Contamination?*** ❑ Yes ❑ No Number of Tanks at Facility Age of Tanks(if available) Type of Tank Steel ❑Fiberglass ❑Single Dual III. TANK HISTORY Was Tank Tested? L3 'Yes No Failed Testing? L3 Yes L3 No If Yes,Provide Dates: Was Tank ystem epaired? j LYes ❑ No If Yes, Describe Repair: ® �- Z® [;AQ res r 4 BTEX IK TPH-G L3 TPH-D L3 LEAD Was epair Done nder Permit? Yes ❑ No Were Soil Samples Analyzed? Yes ❑ No ®-EDB❑OTHER(-z-DC-fl S0AYS Type of Failur ischar ❑ Catastrophic ❑ Long-term Leak ❑ Overfill ❑ Unknown gOther /' a IV. REMOVAL HISTORY(Attach File) Crrvv Soil Samples Received? IfYes ❑ No Seasonal High Depth to GW ft bgs Year/Reference Onsite and/or Nearby Well(s)? ❑Yes XNo L3 Irrigation: # Distance to Tank ft � Score 10 C Score 9 � ❑ Domestic:# Distance to Tank ft 0 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 5 25-501 Fractures in Subsurface(applies to foothill or mountain areas) I ® None Unknown Present Average Annual Precipitation(14 inches for SJC area) -------- <10 9 10-25 -------- 26-402 Man-Made Conduits which Increase Vertical Migration NoneUnknown Present i.e.septic systems,water wells,ponds Unique Site Features:Recharge Area, Coarse Soil(coarse sands, /0 None At Least One More Than One gravels),nearby wells / Column Totals Total Points Z,® ` = y 3 Sample Results for BTEX:Cre Range of Total Points 49 Points or More 4 Points 40 Points or Less `0 400 x.36® Maximum Allowable BTEX B T E X B T E XN/A3 X' Levels m 1.0 50 50 50 0.3 0.3 1.0 1.0 §aWe Results for TPH: Maximum Gasoline 1,000 100 10 Allowable TPH 100 Levels ppm Diesel 10,000 1,000 100 Footnotes: ***If documentecFsoil an 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. STMUECOMMENDATIONI REFERRAL/REVIEW 1. Ar BTEX r TPH Concentrations>Allowable Levels? Xyes ❑ No 2. 1 Is Site Closure Recommended? Yes ❑ No Completed By: !J Date Referred to Site Mi Qgation Unit for Final Actiont Reviewed By: &IeZ Concur with Staff Recommendation Ek-res ❑ No j�zc9 i,7 tAll Cases are Referred to Site Mitigation for Final Action Date Closure Letter Mailed EH 23-0080(Rev 11/14/08)