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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: Ajtp 6-m {AA A 666 SR#: 0(� <br /> ADDRESS: S�' A ky, Lal 6[(�3L CITY: <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: C In— L4�G� G �(/)Z,'P� PHONE: 6125-5-70 �5�3 <br /> FIRE PERMIT#: TANK# 39 UW231bgo - 0165661 <br /> ,PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: MiAniqp4, P&Mu DATE: (a. - pr5- �,V t D <br /> R RINSED: ❑YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> A PURGED: AYES ❑ NO METHOD: cLN L GQ AMOUNT USED: �0 <br /> P 1 <br /> R READINGS AT REMOVAL: L.E.L.: 02: � 'I" COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL .FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION:.,r'GOOD ❑ POOR ❑ HOLES Comments*: kt ru-,+� Ai r1i do ci 0 <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ZrFIBERGLASS ❑ OTHERTOTAL LENGTH OF PIPING a <br /> T PIPE CONDITION:,O GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T li — IS-1 A <br /> A Z �� <br /> N T �l G <br /> K <br /> EXCAVATION SIZE: ' X X17- <br /> Length NIdM 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 /> N Length NAdth Depth <br /> GH DEPTH TO GROUNDWATER: C 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**: ❑YES ❑ 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 />