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SAN JOAQUIN COU6. fY ENVIRONMENTAL HEALT6,,iJEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: SR#: Sle(�D 5`B 4.6 5 <br /> ADDRESS: Z; �5 G(ac4 CITY: <br /> � <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: S_�y�nown ��Z�^ <br /> PHONE: ,0.9� <br /> FIRE PERMIT#: TANK#39- o5?9 <br /> ❑ PIPING REMOVAL 19 UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: ��� <br /> DATE: ti AVIA <br /> R RINSED: .YES Ll NO <br /> METHOD: R lI s� AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> SOTHER TRACKING M <br /> E MANIFEST M <br /> A PURGED: %YES LJ NO METHOD: �(t� 1 ( AMOUNT USED: 6 oo cgs. <br /> P <br /> D <br /> R READINGS AT REMOVAL: L.E.L.: Q 02: •;� COMMENTS*: <br /> C LTANK MATERIAL: -4 STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE Z 632- <br /> 0 K CONDITION: � GOOD ❑ POOR ❑ HOLES Comments*: <br /> S MATERIAL. ❑ STEEL FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ;d GOOD ❑ POOR ❑ HOLES Comments*: rgZytm,Vj,� <br /> DEPTH SOIL YPE OBSERVATION* SAMPLE# <br /> Tom - 1 3 <br /> T <br /> `rPn - i3 <br /> N l� PALE - I <br /> K <br /> EXCAVATION SIZE: _X_ X 1 i <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A <br /> M P ` <br /> I <br /> P P <br /> L E <br /> TRENCH SIZE: X X —~ <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER: Tia FT #HOURS SINCE DEWATERING: <br /> 2 <br /> O SAMPLING METHOD: OBSERVATION*: n <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES AD NO SAMPLE#_ wP T SAMPLE#_CY Z <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**: AYES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />