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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME . tin Pr1 Vast Phi'"i'�- �LS I ( V21� ��- SR# : <br /> ADDRESS : LP �{ h d i ed L OCCi~ CITY : <br /> OWNER NAME : S (S C;1 P1 L� a PHONE : 20 + v2, ( Sq 8 <br /> CONTRACTOR . M (If fz,{ f` rn Th )��' ' - PHONE : c40 (G <br /> FIRE PERMIT # : TANK # 39 D2 U ( 02 <br /> ❑ PIPING REMOVAL DUST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : I • j r Ceti, DATE . �i' / 2, 0t <br /> R RINSED :,00 ES ❑ NO METHOD : 61 e / AMOUNT : /,I G1 led <br /> CI I/U <br /> N RINSATE DISPOSAL SITE : P I Ca V I�'Jo s4e • # '39 `L4L � <br /> S <br /> E MANIFEST M OTHER TRACKING M <br /> P --TPURGED : ;dYES L3NO METHOD : Y 1 GeAMOUNT USED : <br /> R READINGS AT REMOVAL : L. E . L. : I ,y 0 02 : _ COMMENTS* : l <br /> C TANK MATERIAL : wSTEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 3 S C) <br /> 0 TANK CONDITION :,,L ' GOOD ❑ POOR ❑ HOLES Comments* : <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 /> �UC <br /> T ns <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE : X - X -FFr <br /> Length Width Depth <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 Length Width Depth <br /> G H DEPTH TO GROUNDWATER: FT # HOURS SINCE DEWATERING : <br /> 2 <br /> 0 SAMPLING METHOD : OBSERVATION *: <br /> STOCKPILE#1 : _ _ Cubic Yards COVERED: ❑ YES )dNO SAMPLE # S f 9t SAMPLE # K e5'+ <br /> STOCKPILE#2 : <br /> '-`I'- <br /> STOCKPILE#2 : Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : <br /> LABORATORY: Cleo �n 6j [ .J1 CCt t Lao n SAMPLERS NAME : � ( Gha A Ch r r) <br /> CLOSURE IN PLACE . BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED** : YES ❑ NO <br /> EH 23-0043 (Rev 512212007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all commentslobservations ** Site Map Required <br />