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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALOTH DEPARTMENT <br /> USTIPIPING CLOSURE INSPECTION FORM <br /> SITE NAME: �� � � taRYL64LkSR#: Q <br /> ADDRESS: CITY: GIL <br /> OWNER NAME: foPHONE: S 311 <br /> _ <br /> CONTRACTOR: '1,t/ k y/1 J�rp PHONE: . <br /> FIRE PERMIT#: - `� - -- L-�` TANK#39 - � <br /> ❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: <br /> R RINSED: ETHOD: Ir AMOUNT: <br /> I �L U ' <br /> ..� N RINSATE DISPOSAL SITE: p � ' � � ,k c p e U. <br /> S OTHER TRACKING#: <br /> E MANIFEST#: <br /> AMOUNT USED: <br /> A PURGED: YES El NO METHOD: f,. C <br /> P <br /> 0 READINGS AT REMOVAL: L.E.L.: 0 02: COMMENTS*: <br /> R <br /> C TANKMATERIAL: TEEL EJFIBERGLASS L3OTHER TANK SIZE -A <br /> O TANK CONDITION: L3 GOOD OOR ;1 TOLES Comments*: ���, 4 6)k. rY`-4p �t <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> TcSA A SL Ir ti Y <br /> A Sc�,Y�c� S.� <br /> N e r�.� [ <br /> K GYL 6k °� <br /> AA <br /> EXCAVATION SIZEn Xgth Depth-� Ncr <br /> ^Vi � <br /> $ DEPTH SOIL TYPE O SERVATION" �"` i7��25`tr � AMPUE# <br /> A v�Z,-V� <br /> M P <br /> P P l <br /> L E ( o <br /> N TRENCH SIZE: X X <br /> Length wdth Depth r f <br /> G 2 DEPTH TO GROUNDWATER: , _FT #HOURS SINCE DEWAT IN Iv K t ��5� " <br /> 0 SAMPLING METHOD: OBSERVATION*: S� d <br /> YN <br /> TOCKPILE#1: Cubic Yards COVERED: L3 YES L3 NO SAMPLE# G" LE a <br /> STOCKPI# Cubic Yards CO RED: ❑YES ❑ NO SAMPLE#_ SAMPLE# <br /> c� c,UC re lI' 6 +2C {m y4 5;-E e- er o� n <br /> OTHER SAMPLE , P o <br /> LABORATORY: R m-�Y [ SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**:AYES ❑ NO <br /> • <br /> EH 23-0043(Rev 51221207) IMPORTANT NOTES: Complete one form for each tank removed <br /> S, --F, C <br /> �, /*In Jude all commentstobservations **Site Map Required <br />