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SAN JOAQUIN COUNTY ENVIRONMENTAL HEATH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: SR#: <br />ADDRESS: CITY: <br />OWNER NAME: PHONE: %q <br />CONTRACTOR: Wn 6 Ni' X4710% 11 PHONE: 075 <br />FIRE PERMIT #: f — Q 1 v y j TANK # 39-QI7 I N9 ($) <br />PIPING REMOVAL UST EMO CLOSURE IN PLACE ❑ TEMPORARYCLOSURE <br />SPECTOR: DATE: b ti <br />R <br />I <br />RINSED: gyiS ❑ NO <br />METHOD: rf �c,Q, r <br />AMOUNT: <br />N <br />RINSATE DISPOSAL SITE: <br />De e nno Le r40ov1 <br />EMANIFEST <br />S: <br />O S3 b} <br />OTHER TRACKING #: <br />v <br />A <br />P <br />PURGED: ❑ YES ❑ NO <br />METHOD: <br />AMOUNT USED: <br />a <br />READINGS AT REMOVAL: <br />L.E.L.: 02: COMMENTS*: C� I <br />C <br />TANK MATERIAL: (STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE X00 <br />0 <br />TANK CONDITION: ❑ GOOD ❑ POOR )e HOLES Comments*: <br />N <br />S <br />PIPE MATERIAL: STEEL ❑ FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING LLItiY,4,1t1W✓\ <br />T <br />PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments': 6,t o <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE# <br />T <br />604A <br />A SE -102 <br />A <br />SW- 102- <br />N <br />K <br />EXCAVATION SIZE: X 1O X rd-' c-1 V -r— <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />A <br />P <br />yr <br />M <br />P <br />P <br />L <br />E <br />I <br />N <br />TRENCH SIZE: X X <br />^a^ <br />G <br />H <br />DEPTH TO GROUNDWATER: FT <br /># HOURS SINCE DEWATERING: <br />2 <br />0 <br />SAMPLING METHOD: <br />OBSERVATION': �JYY1�o�l <br />STOCKPILE#1:CubicYards COVERED: OYES NO SAMPLE# S I SAMPLE# SI7I GD <br />pn, <br />STOCKPILE#2: Cublc Yards COVERED: OYES NO SAMPLE# 2pZ RP2 SAMPLE# <br />OTHER SAMPLES: I <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED": ES ❑ NO <br />EH 23-M (Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br />. Include all commentsiobservations " Site Map Required <br />