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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : 7- 11 Inc #20632 SR# : 0081819 <br /> ADDRESS : 4627 Da Vinci Dr. CITY : Stockton <br /> OWNER NAME : 7 -Eleven Inc PHONE : 800 -828 -0711 <br /> CONTRACTOR : LC Services PHONE : 559 -444 - 1730 <br /> FIRE PERMIT # : BP17 -06844 TANK # 39 10165883-001 , 002 <br /> PIPING REMOVAL ® UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : Vicky Vang - Lee DATE : 12/01 /2020 <br /> R RINSED : YES ❑ NO METHOD : (r (p /et. re ,- AMOUNT : Z1Q) � e1 <br /> N RINSATE DISPOSAL SITE : too f�m . _C111 , � e � 2"U r%J 6tA^Ael(K 11F, C1T.*.n SOI <br /> EMANIFEST #: �) lz / j � Oc� z� L E OTHER TRACKING #: 2 "Z <br /> A PURGED : YES ❑ NO METHOD : / C' e AMOUNT USED : Af <br /> P <br /> R READINGS AT REMOVAL : L . E . L. : J1 -fit J / to 02 : S ,} -0 G' COMMENTS*: <br /> C TANK MATERIAL : ® STEEL [:] FIBERGLASS ❑ OTHER TANK SIZE (gal) : 10 , 000 <br /> 0 TANK CONDITION : R GOOD ❑ POOR ❑ HOLES COMMENTS* : <br /> N <br /> S PIPE MATERIAL : ❑ STEEL ❑ FIBERGLASS ® OTHER TOTAL LENGTH OF PIPING (ft) : <br /> T PIPE CONDITION : O GOOD ❑ POOR ❑ HOLES COMMENTS* : <br /> DEPTH (ft) SOIL TYPE OBSERVATION* SAMPLE # <br /> T <br /> A 2 ? j69 <br /> N <br /> K ,18 � � +�c P �( vufIL — <br /> EXCAVATION SIZE (length x width x depth ) : 3Z ft X ft X 2 ft <br /> S DEPTH (ft) SOIL TYPE OBSERVATION* SAMPLE # <br /> A P 4/ ihy ,la - L/ <br /> M I <br /> P p <br /> L E <br /> N TRENCH SIZE (length x width x depth) : ft X ft X ft ,� /t "e' . � �1-e <br /> rtiKig IA ' 0 <br /> G H DEPTH TO GROUNDWATER (ft) : �, eKna ;r # HOURS SINCE DEWATERING : (Mk� /1 J9e �� <br /> 2 /10 w4 <br /> 0 SAMPLING METHOD : - OBSERVATION * : <br /> STdCKPSL' � J Z1 Cubic Yards COVERED : El ❑ NO SAMPLE # SAMPLE # <br /> STOCKPILE#2 : Cubic Yards COVERED : ❑ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : �t /� L � t CtiP�xc l - L/ Y /In►� Pl �,iIL 6z - <br /> LABORATORY : f—�J ' " � SAMPLER' S NAME : /cr C <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : /f F} VOLUME : Al <br /> SITE MAP ATTACHED** : YES ❑ NO <br /> EH 23-0043 (Rev 03/04/15) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all comments/observations ** Site Map Required <br />