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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALN DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: SR#: <br />ADDRESS: 5,((i50 W , 7T"ruAd*& R)4CITY: -1 <br />OWNER NAME: 67 MAC �Acw-64 6e , C PHONE: ;21q <br />CONTRACTOR: ':i nGlil �1�Jr;�y�-1 �(t rIJY�W�P.r a� � PHONE: e'�3 a%5-9 11 <br />FIRE PERMIT #: � (x{ ppt{ 1 `i TANK # 39 0S 17 I H1 (/J ) <br />PIPING REMOVAL ,Ig UST REMOVAL ❑ CLOSURE IN PLACE [-]TEMPORARY CLOSURE <br />INSPECTOR: Wlf& I}ti0&2- DATE: (Q • (o .yS_ <br />R <br />I <br />RINSED: OYES ❑ NO <br />METHOD: TVA& r,n �rc L;1 (kw W1060 <br />AMOUNT: <br />N <br />RINSATE DISPOSAL SITE: <br />1n0� <br />EMANIFEST <br />#: <br />qhs 3(o J� k <br />OTHER TRACKING #: <br />V <br />A <br />P <br />PURGED: ❑ YES ❑ NO <br />METHOD: <br />AMOUNT USED: <br />R <br />READINGS AT REMOVAL: <br />L.E.L.: 02: COMMENTS': (,( lid nJ} FD <br />C <br />TANK MATERIAL: L)(STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: CYGOOD ❑ POOR ❑ HOLES Comments': <br />N <br />S <br />PIPE MATERIAL: STEEL ❑ FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments': 0wo <br />DEPTH <br />SOIL TYPE <br />OBSERVATION' <br />SAMPLE # <br />T <br />-A -7 <br />A <br />G <br />1 NHI. <br />N <br />K <br />EXCAVATION SIZE: 0 X 10 X ' `1 GT <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />A <br />P <br />, ttY►tW126w -p tftv <br />M <br />I <br />r✓. I r m fiD 0 <br />P <br />P <br />L <br />E <br />I <br />N <br />TRENCH SIZE: X X <br />G <br />H <br />DEPTH TO GROUNDWATER: FT <br /># HOURS SINCE DEWATERING: — <br />2 <br />0 <br />SAMPLING METHOD: <br />OBSERVATION': <br />STOCKPILE#1: Cubic Yards COVERED: OYES NO SAMPLE# ( SAMPLE# SP 1 C -b <br />STOCKPILE#2: ( Cubic Yards COVERED: L3 YES 9F NO SAMPLESAMPLE# <br />OTHER SAMPLES: <br />LABORATORY: k <br />61 1 <br />22 <br />SAMPLERSNAME: W� 8A/'rtl' &4 <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED": tjYES ❑ NO <br />EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br />Include all commentslobservations **Site Map Required <br />