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SAN JOAQUIN CANTY ENVIRONMENTAL HEARLH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM AAQ- Z <br /> SITE NAME: C I i^�I h F S+064otlj SR#: 0 S L <br /> ADDRESSE u� b W' (1U4L1?! QUL• CITY: [. <br /> OWNER NAME: ` 1 T���� S_ I ac�G� 4^x SI v� ILP�N'1 PHONE: �►Z�i�"]��'/� <br /> CONTRACTOR: -( (L\ASm PC bC �Q IAS PHONE: <br /> FIRE PERMIT#: !,£; YC:j l TANK# 39 <br /> ❑ PIPING REMOVAL W UST REMOVAL Ll CLOSURE IN PLACE LJ TEMPORARY CLOSURE <br /> INSPECTOR: / DATE: <br /> R RINSED: ❑YESNO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S MANIFEST#: OTHER TRACKING M <br /> A PURGED: RYES LlNO METHOD: D rel ��A. AMOUNT USED: L,�S <br /> P 1 <br /> 0 READINGS AT REMOVAL: L.E.L.: D 02: COMMENTS*: U S Y—M j 4119(, bJ4CX rMj <br /> R <br /> C TANK MATERIAL: STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE U AL lUn <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR )(HOLES Comments*: � 1 17) O�00'\ <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 /> T d Cl i S 2 eA <br /> A 7K <br /> N <br /> K <br /> EXCAVATION SIZE: X X _ <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 unn <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: DYES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: AP,A SAMPLERS NAME: tLA(h I <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> Ell 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />