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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM �r� 4(03 <br /> SITE NAME: SNA Qjj SR#: p r7v -20 ( g <br /> ADDRESS: WttA QA,t 6�1 . CITY: <br /> StocutOA— <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: Els i S PHONE: 66 63 ' b g <br /> FIRE PERMIT#: TANK#39 <br /> KPIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: jF- - Y Vk"ap DATE: 9 -- �A <br /> R RINSED: YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: 7— OTHER TRACKING M <br /> V <br /> A PURGED: ❑YES ❑ NO METHOD: AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: L3STEEL FIBERGLASS L3OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P am 0 <br /> M I ar W - - <br /> P p <br /> L <br /> TRENCH SIZE: f X X <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER: —4 k FT #HOURS SINCE DEWATERING: <br /> 2 <br /> p SAMPLING METHOD: KIA OBSERVATION*: WA <br /> STOCKPILE#1: 4\10,t'd Cubic Yards COVERED: ❑YES )kNO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: ( jif <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: (rA.- VOLUME: <br /> SITE MAP ATTACHED**:A, <br /> YES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all comments/observations **Site Map Required <br />