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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: S+. C1 , 6L, _ SR#: 00 S- 2 C7%,- <br /> ADDRESS: 12 �- F 14 ie) e CITY: <br /> OWNER NAME: S;� Ju S irt�dpn �Lt✓v� PHONE: q6b S2 <br /> CONTRACTOR: J, n Ttz co`g, b iZ `�L __ PHONE: - C/R 0 <br /> cl <br /> FIRE PERMIT M t 3 9 TANK# 39 (}� �8 3 <br /> ❑ PIPING REMOVAL FUST REMOVAL ❑ CLOSURE IN PLACE L] TEMPORARY CLOSURE <br /> INSPECTOR: 2 V101i DATE: L O <br /> R RINSED: YES ❑ NO METHOD: (' f n AMOUNT: �(� ( <br /> I <br /> N RINSATE DISPOSAL SITE: 9 (ie� In IA/tC G 4 <br /> S MANIFEST#: lr1 U 1 ? j I LI /� OTHER TRACKING#: <br /> A PURGED: Q$�YYES EINO METHOD: D(. '�'Gp�, AMOUNT USED: rZas <br /> P <br /> 0 READINGS AT REMOVAL: L.E.L.: U 02: �' v(. COMMENTS*: rtjrt �eG(Ad�j — w� C% IC fft 6YV < <br /> R <br /> C <br /> TANK MATERIAL: 4 STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 1 TUU z 41l.oN <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR XHOLES Comments*: �)vpel �ya✓� fn �✓3f Q L fort' Sem <br /> N <br /> S PIPE MATERIAL: Ll STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING pJ f5► ' <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: (/ <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T CL Gro FSGdI rRK1 [C <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: _X_ __X O , <br /> Lw vnau DW <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P P <br /> L E <br /> j <br /> ENCH SIZE: X X <br /> N eneu xtau Dw <br /> G EPTH TO GROUNDWATER: FT =C3AMPLE <br /> E DEWATERING: <br /> *: <br /> AMPLING METHOD: �-p <br /> STOCKPILE#1: 1.O__Cubic Yards COVERED:,(YES NO S #_L f SAMPLE# P <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: n /I,, <br /> LABORATORY: SAMPLERS NAME: C i�I Ll T�� 44 <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED": IYES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all commentstobservations **Site Map Required <br />