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SAN JOAQUIN CIUNTY ENVIRONMENTAL HEATH DEPARTMENT <br /> UST/PI /PING CLOSURE INSPECTION FORM <br /> SITE NAME: C L4: � 940(., L6n 112 �SR#: Q0S_(p27S <br /> ADDRE,' o� 701 W W?6er CITY: Ske-K�'y'1 <br /> OWNER NAME: CY4' ,w( dE i4ij,1tkn PHONE: 6U7 -7r�Y-7 <br /> CONTRACTOR: T04ASM PdrykuM cpq( r f te,,l PHONE:(��o� �7f+'-(o�'T`� <br /> FIRE PERMIT#: 6,117- TANK#39 OS-1773-7 <br /> ❑ PIPING REMOVAL )Z UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: 4 #.J 'Fb-te, DATE: l/ 1 s-/b� <br /> R RINSED: P(YES ❑ NO METHOD:I '�r j e., f AMOUNT: <br /> N RINSATE DISPOSAL SITE: (�/Vi ILVA C I� <br /> EMANIFEST#: DU S �t I 5 3SK_ I OTHER TRACKING M <br /> V <br /> A <br /> P PURGED:�YES Ll METHOD: �1 �� AMOUNT USED: r-o 4 <br /> R READINGS AT REMOVAL: L.E.L.: () 02:� COMMENTS*: <br /> C TANK MATERIAL: �f STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD *A POOR U HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING Vk4t, (JS <br /> T PIPE CONDITION:'n GOOD ❑ POOR ❑ HOLES Comments*: C Ctrjg� /U11tv, c-q .tv j_ <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T — K-,— <br /> A d A C <br /> N <br /> K <br /> EXCAVATION SIZE: 1r XL X 14 <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> MP �' a f ' o cir <br /> I S u✓l I I <br /> L E -1 t K 2 - <br /> t C v a <br /> N TRENCH SIZE: Lab X X <br /> Oyu umu <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: IC 1 SAMPLERS NAME: m I <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED": LYES ❑ NO <br /> EH 23-0043(Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />