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SAN JOAQUIN C, NTY ENVIRONMENTAL HEAPH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: �; SR#: °7 <br /> ADDRESS: CITY: <br /> OWNER NAME: Ba"�dvv, PHONE: ' -) <br /> CONTRACTOR: ,7PHONE: <br /> FIRE PERMIT#: TANK#39 <br /> PIPING REMOVAL(g77 ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: AA wN w2,4- DATE: I Z <br /> R RINSED: AYES ❑ NO METHOD: jAMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E II MANIFEST M OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES V NO METHOD: AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS W OTHER TOTAL LENGTH OF PIPING ((S <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE <br /> T J� s <br /> N ®� <br /> K <br /> EXCA SIZE: X X <br /> Length Width Depth <br /> $ DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> I " ik I K tt h 0 <br /> P P ft <br /> L E Q 0 .t <br /> 1 TRENCH SIZE: ' X 2- ' X 4-/ rr. <br /> N Length Width 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 W NO SAMPLE# A11A 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**: A YES ❑ NO <br /> EH 23-0043(Rev 5/22/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />