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SAN JOAQUIN LC"uTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I VCRKSHEET FOR SITE CLOSURE EVALUATION DAT"c Z I—0 v <br /> NAME Of FACILITY y���hlo� pr� �t +EEPS CODE <br /> ADOR—ESS 5 „'1(l y�Ce—� S �, .�C�UVI l b �1j7iD2. TANK ID # 31-703 <br /> TANK SIZE 16 d00 G FUEL TYPE a <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GL Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) k Type of Tank IS <br /> teel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Vas Tank tested? Yes No failed precision test 1 Yes No If yes, give dates) <br /> jWas a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? YesNo Were soil samples analyzed? Yes V No BTXE 7PH-G X TPH D - Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill j( /unknown other: <br /> ''V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Vater Ref/Year v rye; q91 Average Arcual Precipitation A= 14 10-25 <br /> On-Site VeIL(s) Yes No '� Number b Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to VeLL(s) from Tank k1C'(IC, ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimun Depth to groundwater from the Soil Sample (feet) >100 51-100 5 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration G <br /> of leachate (i.e., septic systems, water wells, ponds) None 1 Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. �j At Least More than <br /> xxxxxx None I one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + F- L4 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B 7 X E 8 JT X1 E <br /> X 2� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1 1. NA\3 <br /> Sanple Result: MAXGASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> N D TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth u5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> II. STAFF RECCMMENDATICN/CCNCLUSICN +t✓-+- (3u+0no) 453v'9� <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recomrend Site Closure Yes No 'If Yes, Refer to Site Mitigation for Evaluation <br /> VII. .REVIEW EVALUATICN - TO BE COMPLETED BY A SUPERVISCR/SENICR <br /> CCNCJR 'WITH STAFF RECOMMENDATION -r CR CLOSURE YES NO REFERRED TO SITE MITIGATICII FOR EVALUATICNIYES ti NO <br /> DATE REFERRED / ; / DATE CLOSURE LETTER MAILED / / <br /> NAME Cf C <br /> �t <br /> E'JAL'JATCR <br /> EH 23 d0 (UGTWKSHT)\5/90 <br />