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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST WORKSHEET FOR SITE CLOSURE EVALUATION I . FACILITY/TANK INFORMATION DATE : it n2 SITE/FACILITY NAME : 43L STATUS CODE : ADDRESS : 6 , 5 U 1J ` Sacr'cur►>�,�- �v S`�' CITY: LD Cef FA#: DOA % Oil PR#: O -sgq 9 s TANK # 39 05 oZ O 8 ,6 TANK SIZE : 1 i utiJ FUEL TYPE : II , GENERAL SITE HISTORY Is Permit Current? Yes ❑ No ❑ NA Documented Soil/GW Contamination ?*** ❑ Yes W/ No Number of Tanks at Facility Age of Tanks (if available) Type of Tank ® Steel ❑ Fiberglass ❑ Single LIDual III . TANK HISTORY Was Tank Tested ? ❑Yes fNo LINA Failed Testing ? ❑ Yes ❑ No O NA If Yes , Provide Dates : MIA Was Tank System Repaired ? ❑ Yes No ❑ NA If Yes , Describe Repair: Was Repair Done Under Permit? ❑ Yes L1 No U( NA Were Soil Samples Analyzed ? I�Yes Ll No BTEX TPH G TPI-I-D LEAD ❑ EDB ❑ OTHER ❑ OXYGENATES Type of Failure/Discharge : ❑ Catastrophic ❑ Long-term Leak ❑ Overfill 2f Unknown ❑ Other IV, REMOVAL HISTORY Attach File Soil Samples Received ? 4f Yes ❑ No Seasonal High Depth to GW 70 ft bgs Year/ Reference oil It Onsite and/or Nearby Well (s) ? C(Yes " i No 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 '1500 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 25 - 501 Fractures in Subsurface ( applies to foothill or mountain areas) Q 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 sstems , water wells , ponds Unique Site Features : Recharge Area, Coarse Soil (coarse sands , to None At Least One More Than One gravels) , nearby wells _ Column Totals Total Points ao 181, + 1 = 47 Sample Results for BTEX: Range of Total Points 49 Points or More 41 — 48 Points 1 40 Points or Less B O T Maximum Allowable BTEX B T E X B T X N/A3 E Levels (ppm) 1 . 0 50 50 50 0 . 3 0 . 3 0 1 . 0 X Sample Results for TPH : Maximum Gasoline 11000 100 10 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? ❑ Yes tA No 2 . If No , Is Site Closure Recommended ? & Yes ❑ No Completed By: Date Referred to Site Mitigation Unit for Final Actiont Reviewed By: Concur with Staff Recommendation ❑ Yes ❑ No tAll Cases are Referred to Site Mitigation for Final Action Date Closure Letter Mailed I I j EH 23 -0080 (Rev 11 / 14/08)