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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: faSR#: OZ:g`1a-a <br /> ADDRESS : - Lt:� fI �pLSZ 0 VQ- CITY: rtro� eAA <br /> OWNER NAME: 0. PHONE: ppq - Q 3 I - lo`(Oo <br /> PHONE: Cj $q j:2Qa - 11 S <br /> CONTRACTOR: Cry wW( 1. ` OY1 q <br /> FIRE PERMIT #: K )5 . 3OA a TANK # 39 TRm5a.o8 �S <br /> ❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: A2IM (R h^pLI DATE : 15 <br /> R =SALSITE: <br /> D: �/� AMOUNT: 1✓k <br /> 1 <br /> N E 1I MICII, OTHER TRACKING #: <br /> A PURGED: YES L3NO METHOD: 'OJo lA5 I Coo 051 AMOUNT USED: Les S <br /> P <br /> D READINGS AT REMOVAL: L.E.L.: NA 02: COMMENTS*: <br /> R <br /> C TANK MATERIAL: xSTEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE LODladL <br /> 0 TANKCONDITION: ❑ GOOD ❑ POOR HOLES Comments*: kQd <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING k) At <br /> T PIPE CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments*: III <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> i Lm u xsau orou <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> AP , N <br /> M <br /> P P <br /> L E <br /> TRENCH SIZE: X X <br /> N L<nYN MI DOM � / <br /> G H DEPTH TO GROUNDWATER: � FT # HOURS SINCE DEWATERING: N <br /> 2 ►✓h <br /> p SAMPLING METHOD: N 0 app OBSERVATION*: <br /> STOCKPILE#7 : NO Cubic Yards COVERED: 13 YES ❑ NO SAMPLE # SAMPLE # <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE #. SAMPLE # <br /> OTHER SAMPLES: 'Vq t IIII vs(clo , o roAQ <br /> LABORATORY: SAMPLERS NA E: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: N VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br /> * Include all commentstobservations ** Site Map Required <br />