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0 6 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: Chevron Station #201383 SR#: 0073163 <br />ADDRESS: 1960 West Eleventh Street CITY: Tracy <br />OWNER NAME: Chevron Products Company PHONE: (925) 842-9002 <br />CONTRACTOR: Gettler-Ryan Inc. (contact - Mike O'Sullivan) PHONE: (925) 551-7888 <br />FIRE PERMIT #: Not applicable TANK # 39 Not applicable <br />® PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: Vicki McCartney DATE: 01/07/2016 <br />R RINSED: ❑ YES ❑ NO METHOD: AMOUNT: <br />I <br />N RINSATE DISPOSAL SITE: <br />S <br />E MANIFEST M OTHER TRACKING M <br />V <br />A PURGED: ❑ YES ❑ 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 (gal): <br />0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES COMMENTS*: <br />N <br />S PIPE MATERIAL: E] STEEL ❑ FIBERGLASS [—]OTHER TOTAL LENGTH OF PIPING (ft): <br />T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES COMMENTS*: <br />DEPTH(ft) SOIL TYPE OBSERVATION* SAMPLE # <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE (length x width x depth): ft X ft X ft <br />S DEPTH(ft) SOIL TYPE OBSERVATION* SAMPLE # <br />A P <br />M I <br />P P <br />L E <br />I <br />N TRENCH SIZE (length x width x depth): ft X ft X ft <br />G H DEPTH TO GROUNDWATER (ft): Unknown # HOURS SINCE DEWATERING: <br />2 <br />O 1 SAMPLING METHOD: Not applicable OBSERVATION*: <br />EH 23-0043 (Rev 03/04/15) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations ** Site Map Required <br />STOCKPILE#1: 12.5 Cubic Yards COVERED: RYES ❑ NO SAMPLE # 4- Waste 1 SAMPLE #4 -Waste 2 <br />STOCKPILE#2: 2.9 Cubic Yards COVERED: ❑ YES []NO SAMPLE # 4 -Waste 3 SAMPLE # <br />OTHER SAMPLES: Soil samples collected under former dispensers: D1/2, D3/4, D5/6, D7/8, D9/10 and D11/12. <br />LABORATORY: McCampbell Analytical Laboratory <br />SAMPLER'S NAME: Mr. Belew Yifru <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: Not applicable <br />VOLUME: <br />SITE MAP ATTACHED**: ® YES ❑ NO <br />EH 23-0043 (Rev 03/04/15) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations ** Site Map Required <br />