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SAN JOAQUIN COI, <br /> TY ENVIRONMENTAL HEAL DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: SR#: S1t-C} CisW - <br /> ADDRESS: 113"t Ave CITY: <br /> OWNER NAME. r��,-� (�,{-L PHONE: <br /> CONTRACTOR: _ r�e2.�yyl gnn �7( c�tN jy� __— PHONE: 17-69) 6 rj 3 - 6 91 <br /> FIRE PERMIT#: _D pp p 0 p �� TANK#39 V S4- gcp;- <br /> ❑ PIPING REMOVAL W UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: t I I 0 <br /> R RINSED: )id YES ❑ NO METHOD: r AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> EMANIFEST#: : OTHER TRACKING#: <br /> 7— <br /> V <br /> A PURGED: 0 YES ❑ NO METHOD: AMOUNT USED: G&O j_,aS <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: Q 02: Z-5 COMMENTS*: <br /> C TANK MATERIAL: )§ STEEL LJFIBERGLASS LJOTHER TANK SIZE S <br /> 0 TANK CONDITION: 3 GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> g PIPE MATERIAL: ❑ STEEL U FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: 11 GOOD ❑ POOR ❑ HOLES Comments*: Ir�,p k4y -orl ,i <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T y3414Up <br /> A r1Y1 — t3 <br /> N t3 <br /> K <br /> EXCAVATION SIZE: _X X t i <br /> Length Wdth Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P 1J /k <br /> M I D <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N Length Wdth Depth <br /> G H DEPTH TO GROUNDWATER: ?� FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES 03 NO SAMPLE# Z AMPLE# �✓�^Z <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: 0.,K , SAMPLERS NAME: <br /> !EjACLOSURE IN PLACE: I BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: &YES ❑ NO <br /> EH 23-0043(Rev 5122!2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />