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• It <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: SR#: 5&05S461!� <br />ADDRESS: ZOO? S f 1Dri�� /i�o1y� CITY: <br />OWNER NAME: ll PHONE: q -Z /,!31 <br />CONTRACTOR: S Y.avn i�x a �o�4 PHONE: fL -n 1%% , "Oil <br />FIRE PERMIT #: OWOOA 4�10 TANK # 39 - pSo q-,gq-(,� <br />❑ PIPING REMOVAL 0 UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: j�. (� yyl DATE: tI1)-?-4pq <br />R <br />I <br />RINSED:'p•YES ❑ NO <br />METHOD: 121 rLV SS <br />AMOUNT: <br />N <br />RINSATE DISPOSAL SITE: <br />S <br />E <br />MANIFEST #: <br />OTHER TRACKING#: <br />V <br />A <br />P <br />PURGED: A YES L) NO <br />METHOD: wL4 � (� <br />AMOUNT USED: (y �j �S <br />R <br />READINGS AT REMOVAL: <br />L.E.L.: O 02: COMMENTS*: <br />C <br />TANK MATERIAL: A STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE -2-637- <br />0 <br />N <br />TANK CONDITION: 1�t GOOD ❑ POOR ❑ HOLES Comments*: <br />S <br />PIPE MATERIAL: ❑ STEEL S FIBERGLASS ❑OTHER <br />TOTAL LENGTH OF PIPING 4 f� C UP.Y}j 4 l <br />T <br />PIPECONDITION: GOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH SOIL YPE OBSERVATION* <br />SAMPLE # <br />T <br />A <br />TW -13 <br />N <br />K <br />l '` S <br />E* - <br />is <br />EXCAVATIONSIZE:�X�$X L <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />A <br />P <br />M <br />I <br />P <br />L <br />p <br />E <br />N <br />TRENCH SIZE: X -- X <br />mp xwn DRn <br />G <br />H <br />2 <br />DEPTH TO GROUNDWATER: _ ?Z FT <br /># HOURS SINCE DEWATERING: <br />0 11 <br />SAMPLING METHOD: <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED: L3 YES O NO SAMPLE# �P - SAMPLE# C, Z <br />STOCKPILER: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: aYES E3NO <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 />