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SAN JOAQUIN C"NTY ENVIRONMENTAL HEAcfH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: Tr.I 26-PrL 5S�-44, SR#: Q6(n {y,,�2 <br /> ADDRESS: S. Cl, CITY: S'&e-L1 kr-4 <br /> OWNER NAME: L-e , PHONE:N&V)ss(a-- Im <br /> CONTRACTOR: p-- 0ati(, . PHONE: 77, - 5(81 <br /> FIRE PERMIT#: ajj,1�Ia ec,IM 0trMIT , 7'4 n V TANK# 39 0X-/ 584;7 <br /> ❑ PIPING REMOVAL `4 UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: V DATE: 16 Q <br /> R RINSED: 9YES ❑ NO METHOD: —ti-i LO 21nto AMOUNT: W-70 / <br /> I p <br /> N RINSATE DISPOSAL SITE: R Upr6y�uVk C� ��/t IC Cp^( y t� p t�ul✓�l <br /> EMANIFEST#: OTHER TRACKING M <br /> A PURGED: YES ❑ NO METHOD: -TGL AMOUNT USED: q D T�fy <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: Q 02: ( , S COMMENTS': r;i`G ��1 l�iti Qn SoLa- <br /> C TANK MATERIAL:ASTEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD POOR ❑ HOLES Comments*: 11 y,, pv a`( <br /> N <br /> S PIPE MATERIAL: L3STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING iV/rllt <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T OIXT Cl ? blko br / yh 1C 1000 sw <br /> A ' n u r ODD✓L Dr garij 6 <br /> N <br /> K <br /> EXCAVATION SIZE: 1F X 1 X 14 <br /> wan <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I A <br /> P P <br /> L E <br /> I TRENCH SIZE: —X—X Z _ <br /> N wan <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: O YES ❑ NO SAMPLE t _- SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: L)YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: eo (\4 SAMPLERS NAME: 001LL G rL <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED":XLYES ❑ NO <br /> EH 23-M3(Rm5/22=7) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all comments/observations **Site Map Required <br />