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• 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: 7 - e Vw SR#: 9�11oZ�� <br /> ADDRESS: `�. S CITY: <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: VJ Cnn fes- rrYZnG PHONE: <br /> FIR <br /> E PERMIT #: X(� r�2�(/�j '`m S1�ac�y aQPr TANK # 39 0935 :Q <br /> ,� PIPING REMOVAL Vj UST REM0 L ❑ CLOSURE IN PLA ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: <br /> R RINSED: Ip,YES ❑ NO METHOD: AMOUNT: G) , mj <br /> I <br /> N RINSATE DISPOSAL SITE: D�2 e nA 0 00-A 26ft a�^ <br /> S <br /> E MANIFEST <br /> #: 0IO OTHER TRACKING#: ~ <br /> P PURGED: �yES L3 NO METHOD: v AMOUNT USED: 3CQ 16 <br /> a READINGS AT REMOVAL: L.E.L.: 02: t/,COMMENTS': c gr <br /> w <br /> C TANK MATERIAL: STEEL ❑ FIBERGLASS A OTHER N 2LA HDPE TANK SIZE (Q l�nO <br /> 0 TANK CONDITION: VLL3POOR L3 HOLES Comments*: No <br /> �elg <br /> N 50-r V-4, ZeL A1� h' <br /> �.�/ <br /> S PIPE MATERIAL: L3 STEEL 4q FIBERGLASS E3 OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION:0 GOOD L3 POOR Ll HOLES Comments*:� <br /> DEPTH SOIL TYPE OBSERVATION* p f SAMPLE# <br /> Si C Z W eS - Cw - 15. <br /> TA c s <br /> N 3 �[ r aS W L-' tf <br /> K <br /> EXCAVATION SIZE: X X <br /> umn mm DV% <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A p a r 6,4 JDC F 0 1 - <br /> M I " S to i/ LI " 35- <br /> P p <br /> L E <br /> I TRENCH SIZE: X X <br /> N I Fmeu mm� D.* <br /> G H DEPTH TO GROUNDWATER: r FT #HOURS SINCE DEWATERING: /V, O�udq ee v✓I <br /> 2 <br /> O SAMPLING METHOD: VL17A A It(*Wj'j OBSERVATION*: r¢f ski+ C Par r�A�0 LLb h r <br /> STOCKPILE#1: Cubic Yards COVERED: OYES 0 SAMPLE# P AMPLE <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> � v <br /> LABORATORY: +I ( SAMPLERS NAME: S 7, <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**:AYES ❑ NO <br /> zi <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />