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SAM JOAQUIM C(,-�MTY EMb1RORdMEMTAL WEAL---M DEPARTMENT <br /> UST/PIPIMG CLOSURE IMSPECTIOPH FORM <br /> SITE NAME: (e r,0(L rj 1ryDel-4� i SR#: 60 7 0 29 <br /> ADDRESS: Tl S�l n). PW y q-`7 CITY: Sh>el V-1pik l <br /> OWNER NAME: &err,-& j -f &LAJU e^, PHONE: qbs, T`E'ST <br /> CONTRACTOR: Z&joij-f, 0/-L PHONE: rcl e l <br /> FIRE PERMIT#: �)� 00 2�Ny5fi TANK#39 19,(o 2(r, <br /> ❑ PIPING REMOVAL WUST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: v DATE: 0l6/05 <br /> R RINSED: BYES ❑ NO METHOD: ("� j,� Y�f� AMOUNT: 4 S v) <br /> I <br /> N RINSATE DISPOSAL SITE: Q rv�trZ Z .�.J be611, <br /> EMANIFEST M 0b2 G ( 1-1 OTHER TRACKING M <br /> V <br /> A PURGED: XYES ❑ NO METHOD: D/'ky T<�QJ AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: '3 02: �,S COMMENTS*: <br /> C TANK MATERIAL: )'STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: GOOD ❑ POOR HOLES Comments*: oil <br /> N <br /> S PIPE MATERIAL: �M STEEL ❑ FIBERGLASS ❑ OTHER I TOTAL LENGTH OF PIPING — C�— <br /> T PIPE CONDITION:)k GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE Al-JA <br /> SAMPLE# <br /> C <br /> T bf N-0 1( Ur-?va r'l 04 ✓tom AALb I <br /> A 4L4-,1 hrl) iVl <br /> N VJ4 . Ci <br /> K <br /> EXCAVATION SIZE: X 6 X <br /> Length NSdth Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P C is D )x, p- I 1,1$Go orrWL. <br /> P p <br /> L E <br /> N TRENCH SIZE: X l X I <br /> Length Width Depth <br /> G 2 DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES KNO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: (fid AAA j �i 6p-C.. =SAMPLERS NAME: VtA <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: WES ❑ NO <br /> EH 23-0043(Rev 5/22/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all comments/observations **Site Map Required <br />