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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: COLMv- Pq IA. Ca.,. P Ro 4 SR#: p p gz ?9r <br /> ADDRESS: 6 a 3 oat,�, i ArvQ . S�o CITY: SIP Cicwv <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: fYlcwifv, rpm PHONE: �u i- 3� `�- <br /> FIRE PERMIT#: TANK#39 <br /> Cif PIPING REMOVAL Ld UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: I DATE: og' 115120 2 v <br /> R RINSED: l6 YES ❑ NO METHO : 'Triple f�nseX wt j-Wzlf �� AMOUNT:/03,43/4 `r 7 1-,"e- <br /> 1 <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: ai- rj- CAL 0 o v 2 p L(2 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: d GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING Z� <br /> T PIPE CONDITION: d GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T i ' �5 :b <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE:i' X 33.1 X <br /> Length Radlh peplh <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> M I <br /> P p <br /> L E <br /> I TRENCH SIZE: _X <br /> N Length Rad Oeplh <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: 940 Cubic Yards COVERED: L3 YES of NO SAMPLE#,59 1,SPa SP-3SAMPLE# SF 6 SP/1, <br /> STOCKPILE#2: -50 Cubic Yards COVERED: ❑YES NO SAMPLE# -Sp91 SAMPLE# 5I lD <br /> OTHER SAMPLES: <br /> LABORATORY: v L�� (N� SAMPLERS NAME:CVAvJ Sc-H fn 0 1 id k,,lu-� P)a4 <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: 6 ra'J.')- VOLUME: <br /> Nil�J OC `�Ljc <br /> SITE MAP ATTACHED**: 4YES ❑ NO <br /> EH 23-0043(Rev 5/2212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />