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SAN JOAQUIN CtrUNTY ENVIRONMENTAL HEAxrH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: L(77J Tj J LQ& 0141A k SR#: <br /> ADDRESS: (�t� S _ E Lomoo �� CITY: S baI-P ►J <br /> OWNER NAME: /V L� PHONE:�yoe) e L(3 'I -Ily <br /> CONTRACTOR: pr p,Z, �L, PHONE: <br /> FIRE PERMIT#: 2i p S�J('iLia�, Rp'f" -r,pAU- TANK#39 O�j <br /> ❑ PIPING REMOVA )KUST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: 16 / 7116 <br /> R RINSED:)4 L3 L3NO METHOD:-rr)0j A, tZj-,V— AMOUNT: <br /> N RINSATE DISPOSAL SITE: U#�g o 1k 'Clk ZA^� G��o�� Itiowti <br /> EMANIFEST M D d 3 �b OTHER TRACKING M <br /> A PURGED: YES ❑ NO METHOD: �(� AMOUNT USED: 20 <br /> P <br /> e READINGS AT REMOVAL: L.E.L.: 02: 2 COMMENTS*: Zn jlt Bw �j J� <br /> C TANK MATERIAL: STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE_ STo 63 gUw� <br /> 0 TANKCONDITION: ❑ GOOD gP00R ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING NDS <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T No DDOIL IT O <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X I X L <br /> wo DOM <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M <br /> P P <br /> L E <br /> TRENCH SIZE: X X <br /> N wf <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATIO <br /> STOCKPILE#1: Cubic Yards COVERED: O YES L3NO VjPLE9 I SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE#_ C" SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: A,�/a ( L�L SAMPLERS NAME: y [AL1 G f � <br /> CLOSURE IN PLACE: I BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED-:AYES ❑ NO <br /> EH 23-0043(Rev 5/22/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />