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SAN JOAQUIN CwUNTY ENVIRONMENTAL HEAti-fH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: 0C. 3l MiJ 2f-9t 6S4te, I'JVai bOev1-- SR#: 66G (O.5-Z <br /> ADDRESS: 7 ( �q e Ir LIJO�� o SIJ CITY: :S �'6C.l�Itoo <br /> OWNER NAME: A/l 7►J �-e PHONE: zo(- <br /> CONTRACTOR: pr b%L ti L . PHONE: <br /> FIRE PERMIT#: aj�� �p SPel�9r� Nb �A 11 o Z TANK#39 QS <br /> ❑ PIPING REMOVAL BUST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: /6 7 416 <br /> R RINSED: YES ❑ NO METHOD: r y Lei 1 , AMOUNT: uw.r <br /> N RINSATE DISPOSAL SITE: <br /> EMAOTHER TRACKING#: <br /> V <br /> A PURGED: YES ❑ NO METHOD: D � AMOUNT USED: �b //p I✓ <br /> P <br /> e READINGS AT REMOVAL: L.E.L.: p,p 02: 3.'l COMMENTS*: <br /> C TANK MATERIAL: X STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE ZL-Y �yq2 . <br /> 0 TANK CONDITION:X GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING N9AQ, <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T D C N 0 0 / B r iSLOl�;ZOh IC J'�a W <br /> A I H kL -F' i CV l brJ seat- TIL, aaw E <br /> N <br /> K t <br /> EXCAVATION SIZE: tom_X , X 11 <br /> wqn Meui waM <br /> S DEPTH I SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N MM DWN <br /> G 2 #HOURS SINCE <br /> DEPTH TO GROUNDWATER: FT DEWATERING: <br /> O 1 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES ).NO SAMPLE#T4'1/' LO SAMPLE# <br /> STOCKPILE92: Cubic Yards COVERED: OYES 4N SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: QI\ SAMPLERSNAME: y C rU�y <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED":IKYES ❑ NO <br /> EH 23-0043(Rev 5122/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all comments/observations "Site Map Required <br />