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0 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: Cj 4-%_A Ok SfiD 6c+0 y-1 SR#: a 0 1p$ 1 1 QP <br /> ADDRESS: �5 7$4 S_ tree Ch Coxh p 120f . CITY: S-rpQ,�<,+0 n <br /> OWNER NAME: �4-U a q -0 C,,�n PHONE: ('2Oq) q 3-2_ 8 $Co q <br /> CONTRACTOR: r0v(y-0 Kj yKer-2tctI PHONE: <br /> FIRE PERMIT#: TANK#39 O 52 U'1 15 <br /> ❑ PIPING REMOVAL ti(UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: S' aA A P, voXA DATE: 9 2 P I I J <br /> R RINSED: ❑YES -' NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING M _— <br /> A PURGED:AYES ❑ NO METHOD: _VY-L) 1 C b AMOUNT USED: 2-7 jo�& <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: C) /. 02: kQ.14 COMMENTS*: <br /> C TANK MATERIAL: brSTEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE Cid <br /> 0 TANK CONDITION: ❑ GOOD V POOR ❑ HOLES Comments*:-Fofj �_ugtS j,n-}��-� lot.i, CXUQI h <br /> N <br /> S PIPE MATERIAL: R TOTAL LENGTH OF PIPING N/A CUS 50 <br /> T PIPE CONDITION: O-GAGE--g-449)R--U-H L- S-Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T Ej I EC '-5 <br /> A q.5 F C- <br /> N <br /> K <br /> EXCAVATION SIZE: �X _X o n a S'Q uAre —A e e rl a <br /> L.0 Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P p <br /> L E <br /> s <br /> I TRENCH SIZE: X X <br /> N ienoth Width D"th <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: O W OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED:"3KYES ❑ NO SAMPLE# SAMPLE# 1506 2 <br /> STOCKPILE#2: 2.5 Cubic Yards COVERED:V(YES ❑ NO SAMPLE# FC— I SAMPLE# rC—:2: <br /> OTHERSAMPLES: ; <br /> LABORATORY: C,l,s. SAMPLERS NAME: v1 r1Ci- wone <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: JSYES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />