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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: hY[p kMP AA 4�Q� SR#: Cd6 lad 5 <br /> ADDRESS: �'G��S.{- ��r_a, .� <br /> CITY: Ltk{A <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: Fyg A fn.G- Li,ddv MC, t?,n ip, PHONE: <br /> FIRE PERMIT#: TANK#39 bg0 -316e6 -6166b2 <br /> P-PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE IQ0941ar <br /> INSPECTOR: MrmiatPgg MAU t -T-kuv TrAn DATE: <br /> R RINSED: ❑XES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> A PURGED: DYES ❑ NO METHOD: LC I ��- AMOUNT USED: :�00 E 16 <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 02: _i� COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL U FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION:-I-GOOD ❑ POOR ❑ HOLES Comments*: '6 (h L b <br /> N <br /> S PIPE MATERIAL: ❑ STEEL -UrFIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING I f- <br /> T PIPE CONDITION: U GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T2 � � ?IB <br /> A 2 ' <br /> N �} G <br /> K <br /> EXCAVATION SIZE: XX <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: X X <br /> NLength Width Depth <br /> GH DEPTH TO GROUNDWATER: �' FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: ,O YES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />