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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/ PIPING CLOSURE INSPECTION FORM <br /> E : �C Vl 10 r; SR#: <br /> SITE NAM � � � � _ <br /> ADDRESS : paid CITY : <br /> OWNER NAME : bra St' PHONE : <br /> 4 <br /> CONTRACTOR: PHONE : <br /> FIRE PERMIT #: V � TANK # 39 015A bCj <br /> ❑ PIPING REMOVAL UST REMOVAL [3CLOSURE IN PLACE L3 TEMPORARY CLOSURE <br /> ft <br /> INSPECTOR : -t len n'; 13 DATE : - (7 " c o t7 <br /> R RINSED : YES ❑ NO METHOD : AMOUNT : cLil ne <br /> �� r TW <br /> N RINSATE DISPOSAL SITE : <br /> S <br /> E MANIFEST # : OTHER TRACKING #: <br /> A PURGED : YES ❑ NO METHOD : � AMOUNT USED : n 1 <br /> P l � <br /> R READINGS AT REMOVAL : L . E . L. : 02 : COMMENTS* : ` � f (� � <br /> C TANK MATERIAL : �. STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE " <br /> 0 TANK CONDITION : L3 GOOD L3 POOR HOLES Comments* : � �-� i ' <br /> N <br /> S PIPE MATERIAL : STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING C <br /> T PIPE CONDITION : ` I GOOD ❑ POOR ❑ HOLES Comments* : <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> T 0 I1C V 0 rtn G `' cuj <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE : _�_ X X ' <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> A <br /> M P <br /> P P <br /> L E <br /> I TRENCH SIZE : X X <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER: FT # HOURS SINCE DEWATERING : /\/A <br /> 2 <br /> 0 SAMPLING METHOD : t�/ A OBSERVATION * : <br /> STOCKPILE#1 : �j— h Cubic Yards COVERED: YES ❑ NO SAMPLE # * n �+l �, `+ SAMPLE # RID CL)) <br /> STOCKPILE#2 : Cubic Yards COVERED : ❑ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : NA <br /> LABORATORY: JEa) v i r p C,C" SAMPLERS NAME : <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> EH 23-0043 (Rev 512212007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all commentslobservations ** Site Map Required <br />