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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: lD P,-4,At4- pa&tbf SR#: <br /> ADDRESS: 44 CITY: <br /> OWNER NAME: (iOl lt5 LPJ/(bIVIA L , PHONE: <br /> CONTRACTOR: hwAkt PHONE: 41gi. j m& <br /> FIRE PERMIT#: _ h titlqTANK #39 CU`s 9,0-­61 <br /> ❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: OS--n I- 14 <br /> R RINSED: -9(,YES ❑ NO METHOD: A& —Wkd , SWr�P-Vtq� & VaC, AMOUNT: <br /> N RINSATE DISPOSAL SITE: CMU. cveoca1 Trd� ' 5 Me/rc� 3 <br /> S <br /> E MANIFEST#: OTHER TRACKING M S 3S <br /> V �N, <br /> A PURGED: ❑ NO METHOD: A , AMOUNT USED: ID <br /> P <br /> 0 READINGS AT REMOVAL: L.E.L.: (� 02: � , COMMENTS': <br /> C TANK MATERIAL: TEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD OOR HOLES Comments*: �( <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING )0- <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: 07 <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE Xa- tz_X <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P P <br /> L E <br /> TRENCH SIZE: X X <br /> N �gffi <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: ftt;i� M r�GCv4140 — q SAMPLERSNAME: �17(iL <br /> CLOSURE IN PLACE: I BACKFILL MIXTURE: NAk VZdj —C GLUME: <br /> SITE MAP ATTACHED**: ES ❑ NO <br /> EH 23"0043(Rev 5122/2007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />