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lop uP r" e <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : SR# : 00T+ 14 <br /> ADDRESS : J�-[ 0OQC« r 1�� , �C CITY : [I( 0. -VI <br /> OWNER NAME : PHONE . <br /> CONTRACTOR : C �.Q�i(` �yOt,Y1 L � C� <br /> PHONE : ala �j - 55 � -- SSSS <br /> FIRE PERMIT # : TANK # 39 <br /> PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : <br /> DATE : F y � - k q <br /> R RINSED : ❑ YES NO METHOD : AMOUNT : <br /> N RINSATE DISPOSAL SITE : <br /> EMANIFEST #: OTHER TRACKING M <br /> V <br /> A PURGED : ❑ YES ❑ NO METHOD : E__: <br /> AMOUNT USED : <br /> P <br /> R READINGS AT REMOVAL : L. E. L . : 02 : COMMENTS* . <br /> C TANK MATERIAL : ❑ STEEL Lk FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION : 1, GOOD ❑ POOR ❑ HOLES Comments* : <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 e W <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE : X X <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> M I 5 i PA5W CJ 6 <br /> P p <br /> L E <br /> I TRENCH SIZE : X X ro <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER: � FT # HOURS SINCE DEWATERING : <br /> 0 SAMPLING METHOD : OBSERVATION* . ` o <br /> STOCKPILE#1 : Cubic Yards COVERED: ❑ YES '&, NO SAMPLE # SAMPLE # <br /> STOCKPILE#2 : Cubic Yards COVERED : ❑ YES 0,NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : <br /> LABORATORY : SAMPLERS NAME : <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : /� VOLUME : <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> r5 - 3 - 3�6 � c <br /> EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all commentsiobservations ** Site Map Required <br />