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SAN JOAQUIN CwJNTY ENVIRONMENTAL HEA�dH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: N' e B I i d.1 FG[Ail, CS{�, 4N VO4 SR#: 006 10 S'2- <br /> ADDRESS: <br /> ZADDRESS: 15L I)w4 o b 94 CITY: <br /> OWNER NAME: MjlJ � fZ PHONE:(4 06 $G( - <br /> CONTRACTOR: 1-(/! 1DtIw Oit- . 60 , PHONE: 72,0 -S-q6 <br /> FIRE PERMIT#: ��/7a ��pL+tK N/ TMIC ( TANK#39C/C-( <br /> ❑ PIPING REMOVAL `,� UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: i✓ DATE: JDI'7``6 <br /> R RINSED:XYES ❑ NO METHOD: -rr,` tR j 9n AMOUNT: <br /> N RINSATE DISPOSAL SITE: �'-4 <br /> EMANIFEST M Qd Oj9 LfFL F OTHER TRACKING M <br /> A PURGED: YES ❑ NO METHOD: AMOUNT USED: <br /> P <br /> 0 READINGS AT REMOVAL: L.E.L.A 6 02: C1q COMMENTS*: �,M j vW A4A- S <br /> R <br /> C TANK MATERIAL:X STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 7 9'by!:5 q2, , <br /> 0 TANK CONDITION:'9C GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING KJ OAJ <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T i G 1 D OWL /r TK -r S1343 W <br /> A 13 r V1 7SUo t <br /> N <br /> K <br /> EXCAVATION SIZE: XIBX tl <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N <br /> G H 11 DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#7: Cubic Yards COVERED: LI YES )i NO SAMPLE# P► AI I /d SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: OYES O NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: bap A AS ( t SAMPLERS NAME: I / U -A <br /> CLOSURE IN PLACE: I BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED'*: YES ❑ NO <br /> EH 23-0043(Rev512YM7) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />