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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST WORKSHEET FOR SITE CLOSURE EVALUATION <br />FACILITYITANK INFORMATION <br />II. GENERAL SITE HISTORY <br />Is Permit Current? Q Yes ❑ No ❑ NA Documented Soil/GW Contamination?*** ❑ Yes Q No <br />Number of Tanks at Facility 4 Age of Tanks (if available) 27 yrs Type of Tank QSteel l✓7Fiberglass ❑Single <br />❑Dual <br />III. TANK HISTORY <br />Was <br />Tank Tested? Bayes ❑No ❑ NA <br />Failed Testing? ❑ Yes `� No ❑ NA <br />If Yes, Provide Dates: <br />Was <br />Tank System Repaired? ❑Yes Q No <br />❑ NA <br />If Yes, Describe Repair: <br />Was <br />Repair Done Under Permit? ❑Yes ❑ <br />No Q NA <br />Were Soil Samples Analyzed? Q Yes ❑ No <br />❑ BTEX Q TPH-G ❑TPH-D Q LEAD ❑EDB <br />Q OTHER: VOCS ❑OXYGENATES <br />Type <br />of FailurelDischarge: ❑Catastrophic <br />❑Long-term Leak ❑Overfill Q Unknown ❑Other <br />IV. REMOVAL HISTORY <br />Attach File <br />Soil Samples Received? Q Yes ❑ No <br />Seasonal High Depth to GW: 40 ft bgs <br />Year/ Reference <br />Fall 2015 <br />Onsite and/or Nearby Well(s)? ❑Yes Q No <br />❑Irrigation: # Distance to Tank ft <br />� <br />Score 10 <br />� <br />Score 9 <br />� <br />❑Domestic: # Distance to Tank ft <br />points if <br />points if <br />Score 5 points if <br />❑Public: # Distance to Tank ft <br />0 <br />R <br />condition is <br />O <br />condition is <br />O <br />condition is met <br />R <br />R <br />E <br />met <br />E <br />met <br />E <br />V. SITE FEATURE —LEACHING POTENTIAL ANALYSIS <br />Minimum Depth to Groundwater from Soil Sample (feet) <br />>100 <br />51 —100 <br />� <br />25 - 50� <br />Fractures in Subsurface (applies to foothill or mountain areas) <br />None <br />9 <br />Unknown <br />Present <br />Average Annual Precipitation (14 inches for SJC area) <br />-------- <br /><10 <br />9 <br />10 — 25 <br />-------- <br />26 - 402 <br />Man -Made Conduits which Increase Vertical Migration <br />i.e. septics stems, water wells, ontls <br />-------- <br />None <br />9 <br />Unknown <br />Present <br />Unique Site Features: Recharge Area, Coarse Soil (coarse sands, <br />ravels nearb wells <br />10 <br />None <br />At Least One <br />More Than One <br />, <br />Column Totals Total Points <br />10 <br />+ <br />27 <br />+ <br />� <br />_ �� <br />Sample Results for BTEX: <br />Range of Total Points <br />49 Points or More <br />41 — 48 Points <br />'40 Poin r Less <br />B <br />T� If �� <br />Maximum Allowable BTEX <br />B <br />T <br />E <br />X <br />B T � X <br />E <br />Levels (ppm) <br />1.0 <br />50 <br />50 <br />50 <br />0.3 0.3 1.0 <br />N/A3 <br />0 <br />X <br />Sample Results for TPH: <br />Maximum <br />Gasoline <br />1,000 <br />100 <br />10 <br />Non -Detected <br />Allowable TPH <br />Levels m <br />Diesel <br />10,000 <br />1,000 <br />100 <br />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). <br />� 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. <br />3 Levels for BTEX are not applicable at a concentration of 10 ppm for TPH—Gasoline or 100 ppm for TPH-Diesel. <br />VI. STAFF RECOMMENDATIONI REFERRALI REVIEW <br />1. Are BTEX or TPH Concentrations > Allowable Levels? [ 1 Yes �No <br />2. If No, Is Site Closure Recommended? Yes ❑ No <br />Completed By: Vicky Vang-Lee <br />Date Referred to Site Mitigation Unit for Final Actions <br />Reviewed �" <br />Concur with Staff Recommendation �es ❑ No <br />Date Closure Letter Mal <br />tAll Cases are Referred to Site Mitigation for Final Action <br />EH 23-0080 (Rev 11/14/08) <br />