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90 <br />SAN JOA UIN COUNTY Q COU ENVIRONMENTAL HEALTHDEPARTMENT <br />SITE NAME: <br />ADDRESS: <br />UST/PIPING CLOSURE INSPECTION FORM <br />SR#: 00,i-fq q.-�AL2 <br />CITY: M otqcc, <br />OWNER NAME: <br />-4-GAeVQA.-,,- <br />METHOD: <br />PHONE: <br />CONTRACTOR: <br />�-c <br />Ibm"C Q3 <br />PHONE: <br />MANIFEST #: <br />i OTHER TRACKING M <br />FIRE PERMIT #: TANK # 39 015156%t 0 <br />*PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLO Al <br />INSPECTOR: a� , n` w DATE: 12 - i0 -- ( 6 <br />R <br />I <br />RINSED: XYES ❑ NO <br />METHOD: <br />AMOUNT: <br />N <br />RINSATE DISPOSAL SITE: <br />S <br />E <br />MANIFEST #: <br />i OTHER TRACKING M <br />V <br />A <br />P <br />PURGED: 0 YES ❑ NO <br />vr <br />METHOD: <br />AMOUNT USED: <br />R <br />READINGS AT REMOVAL: <br />L.E.L.: 02: COMMENTS*: <br />C <br />TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br />S <br />PIPE MATERIAL: ❑ STEEL 04IBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING I�I� <br />T <br />PIPE CONDITION: XGOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE: X X <br />Length Wdth Depth <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />A <br />Pyw <br />do <br />M <br />I <br />— — <br />,,,o r <br />S$ P (o <br />P <br />P <br />L <br />E <br />I <br />NLength <br />TRENCH SIZE: X X �/�} 1 o X (/�/�Vt 11r 1/11 D,` <br />Width Depth v/ 1 v ' `' `- " v"� O / �� ' v .J <br />GH <br />DEPTH TO GROUNDWATER: -- � FT <br /># HOURS SINCE DEWATERING: <br />2 <br />p <br />SAMPLING METHOD: <br />OBSERVATION*: <br />STOCKPILE#1: _-t-VA Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />STOCKPILE#2: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />OTHER SAMPLES: NkW <br />'3, S' auj q S' S , <br />LABORATORY: l�i Ameol-0- <br />SAMPLERS NAME: <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: 'YES ❑ NO <br />W-(�7 ; 50& 5v- WPO4 A r 1'Yla C Q <br />EH 23-0043 (Rev 5/22/2007) 1IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentsiobservations ** Site Map Required <br />