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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 #: <br />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 ? j69N <br />K <br />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 <br />P <br />4/ <br />ihy ,la L/ <br />M I <br />P p <br />L E <br />N <br />TRENCH SIZE (length x width x depth) : ft X ft X ft t <br />e' 1-e <br />rtiKig IA ' 0 <br />G H DEPTH TO GROUNDWATER (ft) : , eKnarHOURSSINCEDEWATERING : Mk 1 <br />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 <br />In <br />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