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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/ PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : D 6 L� <br /> ADDRESS : as 6 rJc s � C r CITY : Lod( <br /> OWNER NAME : V 41 1% C 61 PHONE : X01 — 2S-s26 r <br /> CONTRACTOR : G wt at 6V\ j f•n ee f / e j � �m1.1S � Zll PHONE . -20 ,�D0 <br /> FIRE PERMIT # : TANK # 39 17Jr 8 <br /> ❑ PIPING REMOVAL Ed UST <br /> "REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : ► " �� IvSO DATE . r I 1 2r I `� <br /> R RINSED : ❑ YES ❑ NO METHOD : 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* : <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 ❑ OTHER 7TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments* : <br /> DEPTH SOIL TYPE OBSERVATION * SAMPLE # <br /> T ( E C <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE : 5 X X <br /> Length Width Depth <br /> S DEPTH SOIL TYPE 0 ERVATION * SAMPLE # <br /> A P <br /> M I <br /> P p <br /> L E <br /> TRENCH SIZE : X X <br /> N Length Width Depth <br /> GH DEPTH TO GROUNDWATER : FT # HOURS SINCE DEWATERING : <br /> 2 <br /> 0 SAMPLING METHOD : OBSERVATION* : t- <br /> STOCKPILE#1 : Cubic Yards COVERED : ❑ YES IfNO SAMPLE # S / SAMPLE # J <br /> STOCKPILE#2 : Cubic Yards COVERED : EJ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : i <br /> LABORATORY : (� � � �, SC. I .� ri }-j L � �r I -Q V Y`�ill SAMPLERS NAME : i � � ctM kQ VQ <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED** : d YES ❑ NO <br /> EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Inrlurla all rnmmantslnhservations ** Site Man Reauired <br />