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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> USTIPPIPING CLOSURE INSPECTION FORM <br /> SITENAME: CITI bF TX cy SR#: 00720 <br /> ADDRESS: a l\ ' c4m rg I A- VL CITY: I (tA � ) <br /> OWNER NAME : C I rj D F TOL A C. 1 PHONE: III' 3y- ' 3 > 6w) b <br /> CONTRACTOR: GV PHONE: 9o2f— SIII 331 ?' <br /> FIREPERMIT #: TANK # 39 pS2D $ 4S <br /> ❑ PIPING REMOVAL CJ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: � q � � SD DATE: <br /> R RINSED: ❑ YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> EMW OTHER TRACKING #: <br /> V <br /> A PURGED: ❑ YES ❑ NO OiHe AMOUNT USED: <br /> P <br /> R R rAT 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 TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> T G S <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X E X <br /> i< ou tau o u <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> A P <br /> M I <br /> P P <br /> L E <br /> I TRE X X <br /> N NO ovu <br /> G H DEPTH TO GRO 1J01< naUn FT # HOURS SINCE DEWATERING: <br /> 2 <br /> 0 S NG METHOD: OBSERVATION*: <br /> STOCKPILE#1 : PIIII, Cubic Yards COVERED: OYES l(NO SAMPLE # SP�_I 0 1— SAMPLE # <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES: <br /> LABORATORY: kL C'&M b.11l SAMPLERS NAME: illIGu6L GE 1 <br /> CLOSURE IN PLACE: 61111:11 1141111:11! 11111 ��� I <br /> SITE MAP ATTACHED**: 4fYES ❑ NO <br /> EH 23-0043 (Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> * Include all commentslobservations ** Site Map Required <br />