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SAN ,JOAQ UIN CNTY ENVIRONMENTAL HEAPrH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: SR#: QCT S l 7 <br /> ADDRESS; ���� P4 C.1 1�Z- CITY: y <br /> OWNER NAME: PHONE: (x"62 � `'r2 1 2��'I <br /> CONTRACTOR; - g,D L , PHONE: (01a� ) " -�-2 Z <br /> Q� — 77TANK#39 OS-0 <br /> FIRE PERMIT#: <br /> '"PIPING REMOVAL �'UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE.; !Z it AU—) <br /> R RINSED: KYES ❑ NO METHOD: T!-I LQ-1 AMOUNT: <br /> I <br /> N RINSATE DISPOSAclo s u� <br /> L SITE: ('QVC .I,�r ('rn� �Y <br /> S OTHER TRACKING#: <br /> E MANIFEST#: <br /> ��� �(� <br /> A PURGED: T�YES Ll NO METHOD: b,p AMOUNT USED: 16 , <br /> P <br /> O READINGS AT REMOVAL: L.E.L.: C> 02: ��,(s, COMMENTS*: .4L, Dep1,, 0i1 SC�+�..ti <br /> R <br /> C <br /> TANK MATERIAL: ❑ STEEL )f' FIBERGLASS Ll [TANK <br /> OTHER SIZE- <br /> 0 TANK CONDITION:X GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: L3 STEEL FIBERGLASS El OTHER TOTAL LENGTH OF PIPING �` O <br /> T PIPE CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> I l N! O�. <br /> T 4►k-aT/�- Ji 1-u <br /> A 4 <br /> N 'tr 11 441k 0 �. <br /> K <br /> EXCAVATION SIZE ga <br /> r —� <br /> S DEPTH SOIL TYPE OBSERVATION*th SAMPLE# <br /> A P P-1 S,4-rrS 0 . <br /> M I r <br /> P P D 6 PL- 7 <br /> L E I ,. k U <br /> I TRENCH SIZE: X W • X <br /> Nta„au w�au , <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD; OBSERVATION*: p <br /> PLE# F ti <br /> STOCKPILE#1: S�_. Cubic Yards COVERED:,KYEs :3NO SAMPLE# ,A © — N FI <br /> STOCKPILE#2: � Cubic Yards COVERED:y YES Ll NO SAMPLE# IN! f '15AMPLE# ` <br /> OTHER SAMPLES: S�jckp`+to-, CU, 'Vh( S� PL( y421 <br /> LABORATORY: � (�1 G SAMPLERS NAME: Gam' C I�4r►► <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsfobservations **Site Map Required <br />