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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION CO,)ORM <br />SITE NAME: AAA �7�a/- ��SR#: D <br />ADDRESS: o Ns- c / CITY: <br />OWNER NAME: 5/4 PHONE:, <br />CONTRACTOR:7 % l.� Qom( y k PHONE: <br />FIRE PERMIT M (-p'r 101 &q 1 TANK # 39 <br />❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMP <br />INSPECTOR: <br />DATE: <br />' 1-41-109 <br />RRINSED: <br />YES ❑ <br />AMOUNT: ds <br />N <br />RINSATE DISPOSAL SITE: <br />E <br />MANIFEST #: <br />o o 3 `% ;Lo/ Z <br />OTHER TRACKING #: <br />a me l `71$9 <br />V <br />A <br />P <br />PURGED: YES ❑ NO <br />METHOD: G� <br />AMOUNT USED: 79 SI <br />I <br />D <br />R <br />READINGS AT REMOVAL: <br />L.E.L.: 02: COMMENTS*: <br />C <br />TANK MATERIAL: R/ STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: ❑ GOOD ❑ POOR HOLES Comments*: <br />N <br />S <br />PIPE MATERIAL: E3 STEEL El FIBERGLASS L3 OTHER <br />TOTAL LENGTH OF PIPING >� <br />T <br />PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAI IPLE # <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE: X X <br />wwa <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE# <br />A <br />P <br />a3 2 if ST <br />M <br />I <br />P <br />P <br />L <br />E <br />I <br />N <br />TRENCH SIZE: X X <br />DWM <br />G <br />H <br />DEPTH TO GROUNDWATER: �_ FT <br /># HOURS SINCE DEWATERING: <br />2 <br />0 <br />SAMPLING METHOD: /V, <br />OBSERVATION*: <br />/ <br />STOCKPILE#1: Cubic Yards COVERED:)WYES O NO SAMPLE # ST C—WMPLEk <br />STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY: OIL <br />SAMPLERS NAME: 6S <br />CLOSURE IN PLACE: I <br />BA FILL MIXTURE: N <br />GLUME: <br />SITE MAP ATTACHED**: lid YES ❑ NO <br />EH 23-0043 (Rev 5122/2007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations ** Site Map Required <br />