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SANT JOAQUINI COI,wTY ENVIRONMENTAL HEAL",,,..,DEPARTMENT <br /> USTIPIPINIG CLOSURE INSPECTION FORM <br /> SITE NAME: Lf,rw� 1�l,,,J I GA. , SR#: s�Ld`p 584- U <br /> CITY: <br /> ADDRESS: <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: �,n t ,U,n �y, �Z�c�i✓a PHONE: C1�1 C <br /> FIRE PERMIT#: —h o 0 0-0-0-G-0— TANK#39 - a Ll <br /> ❑ PIPING REMOVAL M UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: t 1 (7-10 <br /> R RINSED: 29 YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> SOTHER TRACKING#: <br /> E MANIFEST#: <br /> vAMOUNT USED: <br /> A PURGED: �YES ❑ NO METHOD: ) L� � <br /> P <br /> D READINGS AT REMOVAL: L.E.L.: 0 02: } - C1 COMMENTS*: <br /> R <br /> C TANK MATERIAL: 'W STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION:'® GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ® FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: Ed GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T til 13 <br /> A 11 (I Ilk ft f l t lM I <br /> N 1t t1 tt 6 - 13 <br /> K <br /> EXCAVATION SIZE: _X 11 <br /> Length mcm Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P r^-o <br /> M 1 <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER: _��_FT #HOURS SINCE DEWATERING: <br /> 2 <br /> p SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: . S --Cubic Yards COVERED: LJ C6 NO SAMPLE# �'�•�f — SAMPLE# SP" Z <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: �u �..tLAh la,t, SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: CTS YES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />