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SAN JOAQUIN C•NTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: T - �,[ I I' SR#: d <br /> ADDRESS: �2 U h-f I li/ C u S ldc Oln CITY: S pC (!v'� <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: / 0 f . I y,, PHONE: <br /> � <br /> FIRE PERMIT#: r/yq/�3 -gym Sr, jQtl� 0 Yl 51'lx TANK# 39 SO q 3L" <br /> ❑ PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPO SURE 0,kAv0V <br /> INSPECTOR: W DATE: <br /> R RINSED: YES ❑ NO METHOD: Y; AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: LL p <br /> S MANIFEST#: O C)3 6 3 t � OTHER TRACKING#: <br /> A PURGED: ❑YES ❑ NO METHOD: Q ry C'� AMOUNT USED: 3Q(' <br /> P to r ver. , 0. <br /> D READINGS AT REMOVAL: L.E.L.: Q 02: COMMENTS*: , raac{ °ILEL P mJ <br /> R Z.� Si+�CG j� �. <br /> C TANK MATERIAL: ,STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 40 K <br /> 0 TANKCONDITION: GOOD E3POOR L3HOLES Comments*: Z°�py� A' r; <br /> N <br /> S PIPE MATERIAL: L3STEEL 96 FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: N 0W±4 6Vt <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T . 5 C 2 w CS) Xw E <br /> A a, cl s <br /> N <br /> K <br /> EXCAVATION SIZE: y.1 X X 13 <br /> U.,N Wkl* Dmf <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A 3,— si e I-. q a r , �uJ 3.5 <br /> M P 3, Ib 0 — 3 . <br /> P P <br /> L E <br /> TRENCH SIZE: X X <br /> N LmgI Wtlt Np% <br /> G H DEPTH TO GROUNDWATER: US 1,5 T #HOURS SINCE DEWATERING: /Vo Q W <br /> OBSERVATION*: V - ( ►10 O W <br /> 0 SAMPLING METHOD: V® 14 U <br /> STOCKPILE#1: C Cubic Yards COVERED: OYES NO SAMPLE# SAMPLE# (a <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: I <br /> LABORATORY: , ( SAMPLERS NAME:Lb qn <br /> CLOSURE IN PLACE: I BA KFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**:AYES ❑ NO <br /> 0 3 <br /> EH 23-0043(Rev 5/2212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />