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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: S�- C A� (j 9'S L-�c/ # /-7 SR#: QQ S 1 7 2 S <br /> ADDRESS: .4c)0(, CITY: <br /> OWNERNAME: h r L �,( PHONE: (S-6 2) c12 / -?J-60 <br /> CONTRACTOR: q -f 4JJ 6 v, PHONE: <br /> FIRE PERMIT#; - TANK#39 QJ-C3 � "� 7 <br /> PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: R q t/o-'-J F,(vt_ DATE: l2, &/0-) <br /> R RINSED: P(YES ❑ NO METHOD: 7~r—2 p Lp, AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: 1041y 0-1�, <br /> S <br /> E MANIFEST M OTHER TRACKING M <br /> V <br /> A PURGED: YES L3 NO METHOD: T��, AMOUNT USED: 26U �7 <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: (� 02: jl COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL X FIBERGLASS ❑ OTHER TANK SIZE 12100-0 F-rr//, <br /> 0 TANK CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL a FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: 5,GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A d rr F3�1 r <br /> Nvi <br /> r <br /> K <br /> EXCAVATION SIZE: Yc5 _X 70 ' X 15- <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A Pcfcf�j --—I - ! S <br /> M I - C *+ r a t <br /> L E 6 I PeA 6j4- �. <br /> o b6v - <br /> 6 1 k I tsj v 0� - <br /> I TRENCH SIZE: X LX_(I <br /> N Length Nadu Depth <br /> G JH DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> SAMPLING METHOD: OBSERVATION*: { �7 <br /> STOCKPILE#1: r�Cubic Yards COVERED:*YES ❑ NO SAMPLE# SP 1 1_NSAMP E# .Sa IA,1 <br /> SAI <br /> STOCKPILE#2: ":1d Cubic Yards COVERED: VYES ❑ NO SAMPLE# �� LSAMPLE# Sa — h) <br /> OTHER SAMPLES: Vve k i It-%4 3 -€D &u, V4f n v <br /> LABORATORY: ( OC I/k SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO I f <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />