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SAN JOAQUIN GI.JNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: (,A GL *� SR#: 00 Z <br /> ADDRESS: R44,74f C VS, CITY: <br /> OWNER NAME: 7tir7� �`j EL PHONE: <br /> CONTRACTOR: PHONE: q&1 kcS(,-)-632 2— <br /> FIRE PERMIT#: — TANK#39 <br /> R PIPING REMOVAL �f UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: V'P_j DATE: <br /> R RINSED: , YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: r`(,V)DuS] r-in A--�ng <br /> S MANIFEST OTHER TRACKING#: <br /> E #: <br /> VAMOUNT USED: 'p� <br /> A PURGED: XYES ❑ NO METHOD: I <br /> P <br /> 0 READINGS AT REMOVAL: L.E.L.: 02: 1 (o COMMENTS*: �,re� Q✓1 'C4'i} Q, <br /> R <br /> C TANK MATERIAL: ❑ STEEL X FIBERGLASS ❑ OTHER TANK SIZE O <br /> 0 TANK CONDITION: )k GOOD ❑ POOR ❑ HOLES Comments*: <br /> S PIPE MATERIAL: ❑ STEEt '§�FIBERGLASS LJOTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION:V GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T n, so/_z <br /> N f O rt wt v <br /> K <br /> EXCAVATION SIZE: _XX—� <br /> Length With 0.PU, _ <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P A tL SV( t <br /> M I 6 <br /> P P 6 QA <br /> L E u <br /> I TRENCH SIZE: X X a'I <br /> N Length YMdih 3-U, <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: I $O CubieYards COVERED: }YE5 ❑ NO SAMPLE —�" M AAPLE#S 2 S M1 I <br /> STOCKPILE#2: 0 0 Cubic Yards COVERED: XYES ❑ NO SAMPLE# "� M 07 AMPLE# <br /> .. hJ <br /> OTHER SAMPLES: pyla- `l0 co). ���{ ����p���� v LJ O4rfb5 <br /> LABORATORY: CPM y11 pLI SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> EH 23-0043(Rev 512212047) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentstobservations **Site Map Required <br />