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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: SR#: <br />ADDRESS: Zyl f; CITY: <br />OWNER NAME: P cr`r PHONE: <br />CONTRACTOR: S WLaly" oto PHONE; (Zoq� �1cl _66yy <br />FIRE PERMIT#: DODOOn An TANK #39— 0 <br />❑ PIPING REMOVAL W UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: DATF: I 111,� I,vQ <br />EH 23-0043 (Rev 5/222007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations « Site Map Required <br />R <br />RINSED: )d YES ❑ NO <br />METHOD: ( �� <br />AMOUNT: <br />N <br />S <br />RINSATE DISPOSAL SITE: <br />E <br />MANIFEST #: <br />OTHER TRACKING #: <br />V <br />A <br />P <br />PURGED: 33 YES ❑ NO <br />METHOD: I LQ_ <br />AMOUNT USED: (566 LAS <br />D <br />R <br />READINGS AT REMOVAL: <br />L.E.L.: O 02: 2.5 COMMENTS": <br />C <br />TANK MATERIAL: 4 STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE 7 S <br />0 <br />N <br />TANK CONDITION: 21 GOOD ❑ POOR ❑ HOLES Comments*: <br />S <br />T <br />PIPE MATERIAL: ❑ STEEL S FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING <br />PIPE CONDITION: & GOOD ❑ POOR ❑ HOLES Comments*: hp <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />T <br />N <br />K <br />i3 <br />13 <br />P <br />1 II <br />a <br />11 11 I 1 <br />6.7— 13 <br />rM-13 <br />EXCAVATIONSIZE: _,�r,' .X -,)t' X R <br />Len9N INdM o.pp <br />S <br />DEPTH <br />SOIL TYPE OBSERVATION* <br />SAMPLE # <br />A <br />M <br />P <br />IS A <br />0 <br />P <br />I <br />L <br />P <br />E <br />N <br />TRENCH SIZE: X —X ^ <br />L.nau nwu, Dean <br />G <br />2 <br />DEPTH TO GROUNDWATER: ?-O FT <br /># HOURS SINCE DEWATERING: <br />0 <br />SAMPLING METHOD: <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED: ❑YES 0 N SAMPLE# Z AMPLE# <br />STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLEk <br />OTHER SAMPLES: <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE: I <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: t4.YES ❑ NO <br />EH 23-0043 (Rev 5/222007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations « Site Map Required <br />