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SAN JOAQUIN COJNTY ENVIRONMENTAL HEAL-i'H DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />�- n^ c— /6 C// <br />SITE NAME: IS S C0M,2 LLL,A6*,l SR#. <br />ADDRESS: 'I u Z If E MAI' I PoS A- Qp r *7 Cn 1 S. gt4t 'l CITY: S' (JC %jo <br />OWNER NAME: <br />CONTRACTOR: <br />FIRE PERMIT #: <br />❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE <br />INSPECTOR: 04-1 V0,1 rl(ti <br />PHONE: 41PI -00�j? <br />PHONE: 3-`f8/ <br />TANK#39 <br />❑ TEMPORARY CLOSURE <br />: 8/z8A)-2 <br />DATE <br />R <br />RINSED: KYES ❑ NO <br />METHOD: A <br />AMOUNT: <br />I <br />N <br />RINSATE DISPOSAL SITE: <br />vrk, <br />EMANIFEST <br />M <br />O G' C <br />OTHER TRACKING M <br />VAMOUNT <br />A <br />PURGED: YES ❑ NO <br />METHOD: <br />USED: <br />P <br />0 <br />R <br />READINGS AT REMOVAL: <br />L.E.L.: 02: 0, COMMENTS*: <br />C <br />TANK MATERIAL: STEEL L3 FIBERGLASS L3OTHER S �� <br />TANK SIZE U !30 G! <br />0 <br />TANK CONDITION: IX GOOD ❑ POOR ❑ HOLES Comments*: N 6 V 1$ 15� <br />N <br />S <br />PIPE MATERIAL: STEEL L3FIBERGLASS L3OTHER <br />TOTAL LENGTH OF PIPING % <br />T <br />PIPE CONDITION:')/ GOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br />T <br />$ No DYSr✓ I>�` ' DDD GI t'K <br />A <br />I% A * � ^ � ' 1 { oN 2 <br />N <br />K <br />EXCAVATION SIZE: S S X I? X Z— <br />�0 <br />S <br />OBSERVATION* SAMPLE # <br />A <br />p <br />' �^ DVS Ani <br />M <br />I <br />FTRENCH <br />tSIZE:x <br />P <br />PL <br />E <br />N <br />X _L'v_ <br />�^ <br />G <br />H <br />DEPTH TO GROUNDWATER: FT # HOURS SINCE DEWATERING: <br />2 <br />0 <br />SAMPLING METHOD: OBSERVATION*: <br />/ — <br />STOCKPILE#7IU : I SCubic Yards COVERED: O YES XNO SAMPLE#SOI �o SAMPLE# <br />STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE # SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY: be -0 AqkkAk <br />SAMPLERS NAME: (Z L 14 C 11 <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: -- <br />SITE MAP ATTACHED": YES ❑ NO <br />EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentstobservations ** Site Map Required <br />