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SAN JOAQUIN CO TY ENVIRONMENTAL HEA H DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: SR#: S 6 6z-S- <br /> ADDRESS: 1091 p CITY: <br /> OWNER NAME: PHONE: _ t <br /> CONTRACTOR: - PHONE: <br /> FIRE PERMIT#: TANK#39 <br /> tA PIPING REMOVAI(etI) ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: tM wn( G DATE: e5 1,-,?',1 / Z- <br /> R RINSED: 0 YES ❑ NO METHOD: f AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES NO METHOD: AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: IVIA <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS 09 OTHER [ TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS 14 OTHER TOTAL LENGTH OF PIPING I IG <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR HOLES Comments*: 4 0 6pz, C �_ct <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE <br /> T <br /> A <br /> N <br /> K <br /> ON SIZE: X X <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A p tga,, 6V`d[E <br /> M I n rr i It cr ri <br /> P P <br /> L E r< <br /> N TRENCH SIZE: ^ X X c ' <br /> Length Width Depth <br /> GH DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: �� Cubic Yards COVERED: E3 YES THNO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: U(„ <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: N YES ❑ NO <br /> EH 23-0043(Rev 5/22/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />