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SAN JOAQUIN e: JNTY ENVIRONMENTAL HEATH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: < SR#: �� O�s��I3 <br /> ADDRESS: L5it "-i)p CITY: 214n <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: � 7, PHONE: <br /> FIRE PERMIT#: _ ��/ TANK#39 D <br /> ❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TE.IIpPO R`Y CLOSURE <br /> INSPECTOR: iIm DATE: �fI Z QO/ <br /> R RINSED: YES ❑ NO METHOD: AMOUNT: JS 9 <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> SOTHER TRACKING M <br /> E MANIFEST M <br /> V <br /> A PURGED:J�YES L3NO METHOD: Z AMOUNT USED: I 5 <br /> P <br /> D READINGS AT REMOVAL: L.E.L.: 0 02: 'I COMMENTS*: <br /> R <br /> C TANK MATERIAL:P STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD�6 POOR )q HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> TA <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> EXCAVATION SIZE: 13 X -5 X <br /> � v�u <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N D.0 <br /> G H DEPTH TO GROUNDWATER: 3�FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: AmtlOBSERVATION': <br /> STOCKPILE#7: Cubic Yards COVERED:XYES ONO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: O YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: 4go <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED": AYES ❑ NO <br /> EH 23-OD43(Rev 5/29J2007) IMPORTANT NOTES: Complete one form for each tank removed <br /> Include all commentsiobservations **Site Map Required <br />