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SAN JOAQUIN'CATY`ENVIRONMENTAL HEALAH DEPARTMENT UST/PIPING CLOSURE INSPECTION FORM SITENAME: SR#: &(5--7q4g ADDRESS: 3 CITY: OWNER NAME: PHONE: CONTRACTOR: i v PHONE: '/ - FIRE PERMIT #: TANK # 39 fj LA F1 PIPING REMOVAL' F-1 UST REMOVAL.' CLOSURE IN PLACE F-1 TEMPORARY CLOSURE INSPECTOR: 7,,,CtKDATE: Drx, 0 R 1 RINSED: R] F1 YES NO METHOD: 67 j AMOUNT: 3X 57 N RINSATE DISPOSAL SITE: S E MANIFEST #: OTHER TRACKING M V A P PURGED: F1 YES F1 NO METHOD: AMOUNT USED: 0 R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: C TANK MATERIAL: El STEEL El FIBERGLASS F I OTHER rj LA TANK SIZE: A/ L 0 . TANK CONDITION: [:] GOOD El POOR El HOLES COMMENTS*: t\JA N S PIPE MATERIAL: F1 STEEL F] FIBERGLASS ROTHER I TOTAL LENGTH OF PIPING: T PIPE CONDITION:Jg GOOD R POOR F1 HOLES COMMENTS*: DEPTH SOIL TYPE OBSERVATION* SAMPLE # T A N K EXCAVATION SIZE (length x width x depth): X x S DEPTH SOIL TYPE OBSERVATION* SAMPLE # A P M I P P L E I N TRENCH SIZE (length x width x depth): X X G H DEPTH TO GROUNDWATER: ft IV # HOURS SINCE DEWATERING: 2 ^j 1A SAMPLING METHOD: OBSERVATION*: GQ r /%0 le- STOCKPILE#1: Cubic Yards COVERED: El YES 0 NO SAMPLE# SAMPLE# 2A STOCKPILE#2: Cubic Yards COVERED: El YES El NO SAMPLE# SAMPLE# NjA OTHER SAMPLES: LABORATORY: ray,lSAMPLER'S NAME: -3 Ze CLOSURE IN PLACE: I BACKFILL MIXTURE: a " 0 4- P VOLUME: SITE MAP ATTACHED**:.N YES ❑ NO &I( EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed * Include all commentsiobservations ** Site Map Required I