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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: SR#: d go <br />CITY: <br />ADDRESS: <br />OWNER NAME: PHONE: <br />CONTRACTOR: PHONE: <br />FIRE PERMIT #: TANK # 39 r „ <br />❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY L0SUREo�� 3 <br />IAICPFrTnR- �I I A -A "�1� A ii'j DATE: i <br />R <br />RINSED: LlYES LlNO <br />METHOD: o� `00 <br />AMOUNT: <br />I <br />N <br />RINSATE DISPOSAL SITE: <br />EMANIFEST <br />V(6P,AMOUNT <br />#: OTHER TRACKING #: <br />LJ PURGED: YES L3 NO METHOD: <br />USED: <br />P <br />0 <br />R <br />-- <br />READINGS AT REMOVAL: <br />L.E.L.: ,, 02: COMMENTS*: <br />TANK MATERIAL: STEEL L3FIBERGLASS LJOTHER l�,wa�l <br />TANK SIZE <br />C <br />0 <br />' <br />TANK CONDITION: GOOD ❑ POOR 1 QOLES Comments*: 92� <br />N <br />S <br />PIPE MATERIAL: TEEL L3 FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: S5 . 1 t &-- <br />SOIL TYPE OBSERVATION* <br />SAMPLE # <br />DEPTH <br />l <br />r <br />�s <br />T <br />N <br />K <br />EXCAVATION <br />SIZE: XX <br />Length Width Npth <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />A <br />M <br />P <br />P <br />P <br />L <br />E <br />I <br />NLength <br />TRENCH SIZE: X X <br />Nfidth Depth <br />G <br />H <br />2 <br />O <br />DEPTH TO GROUNDWATER: FT <br />SAMPLING METHOD: <br /># HOURS SINCE DEWATERING: <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br />STOCKPILE#2:_ Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY:' -� <br />SAMPLERS NAME: (n <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: ❑ YES ❑ NO <br />EH 23-0043 (Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Pnrluria all rnmmpntslobservatlonS "Site Map Required <br />