Laserfiche WebLink
0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: MAdA � bA ,✓ 4 l C\ % SR#: SIUOSE+ G S <br />ADDRESS: 23cI c p c.4 fw. �T f2 y1_pn•• CITY: <br />OWNER NAME: <br />PHONE: q - Zf S 1 <br />CONTRACTOR: SaLzej 1/1 a,,,, c.a,✓ 47e PHONE: G C 9 q <br />FIRE PERMIT #: ho 0 (3 0 d, (� 0 TANK # 39 - 6),s -t)4 8 ll t, <br />❑ PIPING REMOVAL 13 UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: h - �pA-tftAA DATE: l l IIZI Oct <br />R <br />I <br />RINSED: 5 YES ❑ NO <br />METHOD: <br />AMOUNT: <br />N <br />RINSATE DISPOSAL SITE: <br />S <br />E <br />MANIFEST M <br />OTHER TRACKING #: <br />A <br />P <br />PURGED: t4 YES ❑ NO <br />METHOD: t <br />AMOUNT USED: <br />a <br />READINGS AT REMOVAL: <br />L.E.L.: O 02: J . q COMMENTS*: <br />C <br />TANK MATERIAL: U STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: 'W GOOD ❑ POOR ❑ HOLES Comments*: <br />N <br />S <br />PIPE MATERIAL: ❑ STEEL 3 FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: at GOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH <br />SOIL TYPE OBSERVATION* <br />SAMPLE # <br />T <br />I <br />- 13 <br />A <br />II f 1 II \ II II <br />Tim — I <br />N <br />I l l 11U <br />TG— f <br />K <br />EXCAVATION SIZE: X —7fl-L X <br />Feu xwm Dm <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />AP <br />No <br />M <br />P <br />P <br />L <br />E <br />N <br />TRENCH SIZE: X — — X <br />Lenyu xwn Dwu <br />G <br />H <br />DEPTH TO GROUNDWATER: �?�J _ FT <br /># HOURS SINCE DEWATERING: <br />2 <br />0 <br />SAMPLING METHOD: <br />OBSERVATION*: <br />STOCKPILE#1: _Cubic Yards COVERED: ❑YES ISl. NO SAMPLE# St?I SAMPLE# SP -7, <br />STOCKPILE #2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY: �U Q✓ G�tn <br />/ <br />SAMPLERS NAME: ,6) etFG� <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: L9 YES ❑ NO <br />EH 23-0043 (Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations ** Site Map Required <br />