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r n 0 <br /> SAN JOAQUIN CI'NTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: Vv a I rLew s SR#: <br /> ADDRESS: h' ay ip os,,- ci- �aV-yV;rlr e.8 CITY: -"6 <br /> OWNER NAME: l lh�r`Q. Ms PHONE: . 5 g 911 3 <br /> CONTRACTOR: P � � PHONE: 0 -43,4-9 2GC) <br /> FIRE PERMIT#: d TANK# 39 - 0-52-0 L�S4 <br /> ❑ PIPING REMOVAL ❑ UST REMOVAL ,CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: 1012_ 11 D L l <br /> R RINSED: DYES NO METHOD: K ' `( Y�r7 AMOUNT: jr jr�s <br /> I <br /> N RINSATE DISPOSAL SITE: Wo 4 <br /> S <br /> E I MANIFEST#: OlAkOtls I OTHER TRACKING#: <br /> V <br /> A PURGED: El YES ❑ NO METHOD: r `/ C AMOUNT USED: <br /> P l� <br /> R READINGS AT REMOVAL: L.E.L.: O( 02: COMMENTS*: t- <br /> C TANK MATERIAL: A STEEL ❑ FIBERGLASS El OTHER TANK SIZE 'v U <br /> 0 TANK CONDITION: ® GOOD ❑ POOR 0 HOLES Comments*: J IT <br /> 9 G je <br /> aa!4f�' sM. <br /> NHw4,P k I <br /> g PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH O P ING <br /> ft <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> N fik ,nor rr cx�o r '� vx ;c 1 -f .S .5 <br /> nor , s� <br /> K a, © o✓ �Flo r�-�n S y� C32 � .01{, ` <br /> EXCAVATION SIZE: 1 X _ X 5` SQS C9 4iMR Vj ! <br /> Length YMdCi OWth <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 Menem �nau Depth <br /> GDEPTH TO GROUNDWATER: N FO FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 <br /> GH DEPTH <br /> METHOD: IN OBSERVATION*: 1 p <br /> STOCKPILE#); � 16 Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# '1.` SAMPLE# s1 <br /> STOCKPILE##: LM Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SP A SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: !YES ❑ NO <br /> 6L d� k^ <br /> M <br /> EH 23-0043(Rev 512212007) C S IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />