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SAN JOAQUIN Cbw4NTY ENVIRONMENTAL HEAromJ4 DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: (tee rp,f� &L tJAL.- E { SR#: GYMS -20 <br /> ADDRESS: ►\), g W\-/ CITY: 10611,kiO <br /> OWNER NAME: &,et orU j 4 Ly &UN Cf'- PHONE: ��js- ?07S-!r <br /> CONTRACTOR: -17/yl Q/)- PHONE: 32' - _�-qg j <br /> FIRE PERMIT#: 6)01 () 2 -fg b I TANK#39 DT t 967-7 <br /> L3PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE L3 TEMPORARY CLOSURE <br /> INSPECTOR: U`e.� DATE: P`6�� <br /> R RINSED: YES ❑ NO METHOD: AMOUNT: /L i✓ <br /> N RINSATE DISPOSAL SITE: <br /> EMANIFEST#: Z'1 OTHER TRACKING#: <br /> V <br /> A PURGED: RYES ❑ NO METHOD: —,rce, AMOUNT USED: �d l <br /> RP �� <br /> READINGS AT REMOVAL: L.E.L.: 3 02: COMMENTS*: p/0 /Whol, /1,&,j I �/Z, <br /> C TANK MATERIAL: 1(STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 5A1. r <br /> 0 TANK CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: LIS4 , m " MUL IOPJ`I i-►s wGta( <br /> N <br /> S PIPE MATERIAL:' STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: X GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T 3 (ft ffb 2600 <br /> A C3 o✓u -1 613V $ <br /> N jj v <br /> K <br /> EXCAVATION SIZE: D X _X�( <br /> Length mcith Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P b c5 K, -t41 w- <br /> M I d f3 7 <br /> P P <br /> L E <br /> I TRENCH SIZE: � ,?' X c, 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: 60 Cubic Yards COVERED: ❑YES LLNO SAMPLE# SAMPLE# <br /> STOCKPILE#2: b Cubic Yards COVERED: O YES & NO SAMPLE# �i—1 SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: e o 4prA j L SAMPLERS NAME: Ln'Q' <br /> CLOSURE IN PLACE: BAC FILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> EH 23-0043(Rev 5/22/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />