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---------- <br /> ................... <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> USTIPIPING CLOSURE INSPE51TION FORM <br /> , -� �0"< <br /> SITE NAME: SL 0& 6" VSR9: <br /> ADDRESS: -U),e j2er— CITY: <br /> PHONE: ?19 <br /> OWNER NAME: to- <br /> CONTRACTOR: VV PHONE: -Z-� <br /> FIRE PERMIT#: -1 L-4- TANK#39 2--P <br /> L3 PIPING REMOVAL T REMOVAL ❑ C OSURE IN PLACE El TEMPORARY CLOSURE <br /> INSPECTOR: DATE: <br /> RINSED: 0 YES Ll NO METHOD: AAA MIT- <br /> RINSATE DISPOSAL SITE: <br /> S MANIFEST#: KING#: <br /> r- <br /> V AMOUNT USED: <br /> A� PURGED: El YES U NO METHOD: <br /> P <br /> 0 <br /> READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: TEEL Ll FIBERGLASS 0 OTHER TANK SIZE <br /> 0 TANK CONDITION: 0 GOOD POOR Ll HOLES Comments*: <br /> N <br /> 8 PIPE MATERIAL: El STEEL 15 FIBERGLASS U OTHER TOTAL LENGTH OF PIPING <br /> LTj PIPE CONDITION: L3 GOOD LJ POOR L3 HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K 0" <br /> EXCAVATION SIZE: X y <br /> Lngth Wdth r <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P P <br /> L E <br /> I TRENCH SIZE: —X—X <br /> N LeMN Width Depth <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: E)YES E) NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: L3 YES LJ NO SAMPLE#_SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**.--*ES L3 NO <br /> 0't===77--,n,, <br /> �14&tal , (- - pqq-(ke F r o ��FsJ,, <br /> -or I! I +- (), V � 4M <br /> EH 23-0043(Rev 5122J2 7) 454ejQ_ AIAJI I-4-IMPORTANT NOTES: Complete one form for each tank removed <br /> cc-m,p(a 4- Include all commentslobservations **Site Map Required <br />