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SAN JOAQUIN CbvONTY ENVIRONMENTAL HEALwi DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: (7jerAV) t juPJ�t^,- PrOP r SR#: <br /> ADDRESS: T�4A ti , 14 W\-1 CITY: <SAx4kt-i <br /> OWNER NAME: (ocf&t r,) -f L!/ 6j(JN 4eA-, PHONE: C46,50— <br /> CONTRACTOR: -Sc, M 1(�,Vr jy/`L PHONE: ?Lj - YC-181 <br /> FIRE PERMIT#: _(9 0/Qb_ 2�-j�-1 (9 �_ TANK#39 L,2Y / P(o-76 <br /> ❑ PIPING REMOVAL )�k UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: (&`a <br /> R RINSED: ES ❑ NO METHOD: i�J(� c.� AMOUNT: ��L -50t. <br /> I <br /> N RINSATE DISPOSAL SITE: /Lne-r1 &Vj q <br /> EMANIFEST OTHER TRACKING M <br /> V <br /> A PURGED: ES L3NO METHOD: D r _ AMOUNT USED: OU <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: (� 02: �, q COMMENTS*: 1" j'VJ fhej-w J 1 b/#,b -J Z <br /> C TANK MATERIAL: STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE r04y 45 <br /> 0 TANK CONDITION: tX GOOD ❑ POOR ❑ HOLES Comments*: 'l, <br /> N <br /> S PIPE MATERIAL: STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING 3s� <br /> T PIPE CONDITION: ❑ GOOD POOR ❑ HOLES Comments': <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T ( C PsL b ONJ p/` %S G b/b"/ j-�.� Ca ll V N <br /> A l C, 5z 6LT0 <br /> N <br /> K <br /> 4 <br /> EXCAVATION SIZE: '2a' X t X (� <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P p <br /> L E <br /> I TRENCH SIZE: 3_X 4 X?L— <br /> N Length Width Depth <br /> G IH DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: _420 Cubic Yards COVERED: ❑YES NO SAMPLE# SAMPLE# Sp Lf <br /> STOCKPILE#2: [J p Cubic Yards COVERED: ❑YES 0 SAMPLE# SAMPLE# SPI., <br /> OTHER SAMPLES: <br /> LABORATORY: ^ T SAMPLERS NAME: Vcl <br /> CLOSURE IN PLACE: BACKFILL 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 commentslobservations **Site Map Required <br />