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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: es (-u o CA SR#: 3L <br />ADDRESS: <br />OWNER NAME <br />[ter►III icTT@]-to]IN <br />I/1 CA CITY: 3� <br />l�Q`%Qfj PHONE: 4 1- 0sq - j of Q <br />n LA S PHONE: aR ►J -)-� - 3 <br />FIRE PERMIT #: TANK # 39 <br />d. PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: eCn (U,',� DATE: <br />R <br />I <br />N <br />S <br />E <br />RINSED: ❑ YES ❑ NO METHOD: AMOUNT: <br />RINSATE DISPOSAL SITE: W o`T CL (,lam CX <br />MANIFEST #: OTHER TRACKING #: <br />V <br />A <br />P <br />R <br />PURGED: ❑ YES ❑ NO <br />READINGS AT REMOVAL: <br />METHOD:_ AMOUNT USED: <br />L.E.L.: 02: COMMENTS*: <br />C <br />TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br />S <br />PIPE MATERIAL: ❑ STEEL FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: GOOD ❑ POOR L3 HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE: X X <br />Length Width Depth <br />S <br />(��� <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />A <br />M <br />N v <br />-z <br />P <br />1 -- %jo cAw <br />D '02 <br />L <br />.D ' b -Me 60-F <br />D <br />N <br />TRENCH SIZE: X(_X U�C <br />Length Width Depth <br />GH <br />H <br />TO GROUNDWATER: ' FT <br /># HOURS SINCE DEWATERING: tjA <br />2 <br />0 <br />SAMPLING METHOD: <br />: <br />OBSERVATION*: NA <br />STOCKPILE#1: Cubic Yards CO RED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY:22& <br />SAMPLERS NAME: ray <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME. <br />SITE MAP ATTACHED**: YES ❑ NO <br />EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all comments/observations ** Site Map Required <br />