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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: CITY OF STOCKTON SR#: 0073144 <br /> ADDRESS: 800 E. MAIN ST. CITY: STOCKTON <br /> OWNER NAME: CITY OF STOCKTON PHONE: 209-937-8374 <br /> CONTRACTOR: ADVANCED GEOENVIRONMENTAL, INC PHONE: 209-467-1006 <br /> FIRE PERMIT#: SP15-260 TANK#39 TA0520791 <br /> ❑ PIPING REMOVAL ® UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: CINDY VO DATE: December 2, 2015 <br /> R RINSED: ®YES ❑ NO METHOD: TRIPLE RINSED ON 11/12/15 AMOUNT: 200 GALLONS <br /> I <br /> N RINSATE DISPOSAL SITE: DK DIXON 7300 CHERVON WAY <br /> S <br /> E MANIFEST#: 002828850GBF OTHER TRACKING M <br /> V <br /> A PURGED:®YES ❑ NO METHOD: INERT DRY ICE AMOUNT USED:20 LBS <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 2 02: 8 COMMENTS*:WHEN TANK WAS IN THE PIT <br /> C TANK MATERIAL: ®STEEL ❑ FIBERGLASS ❑OTHER TANK SIZE(gal):300 <br /> 0 TANK CONDITION: ❑GOOD ❑ POOR N HOLES COMMENTS*:OBSERVED TWO HOLES (SEE SITE MAP) <br /> N <br /> S PIPE MATERIAL: ❑STEEL ❑ FIBERGLASS ❑OTHER 7 TOTAL LENGTH OF PIPING(ft): <br /> T PIPE CONDITION: ❑GOOD ❑POOR ❑HOLES COMMENTS*: <br /> DEPTH(ft) SOIL TYPE OBSERVATION* SAMPLE# <br /> T 8 CLAY DARK COLORED SOIL WITH NO DISCOLORATION "tank 18" <br /> A AND NO ODOR NEAR PIT. <br /> N <br /> K <br /> EXCAVATION SIZE(length x width x depth): 9 ft X 5 ft X 7.5 ft <br /> S DEPTH(ft) SOIL TYPE OBSERVATION* SAMPLE# <br /> A P 2 CLAY UNKNOWN LENGTH OF EXPOSED PIPING El- NO SAMPLES TAKEN <br /> M I BELOW ASPHALT INSIDE THE PIT CONTAINING <br /> P P BLACK WET SLUDGE. <br /> L E <br /> NTRENCH SIZE(length x width x depth): ft X ft X ft <br /> G H DEPTH TO GROUNDWATER(ft): #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: 10 Cubic Yards COVERED:RYES ❑NO SAMPLE#"stockpie 1" SAMPLE#"stockpie 2" <br /> STOCKPILE#2: Cubic Yards COVERED: []YES ❑NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: PRECISION ENVIRO-TECH SAMPLER'S NAME:DON NGO <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: ®YES ❑ NO <br /> EH 23-0043(Rev 03/04/15) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />