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t It SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UST/PIPING CLOSURE INSPECTION FORM SITE NAME: r p v�� QYa,[L SR#: ADDRESS: 2 CITY: OWNER NAME:Pa&-A'C- TtftLCVjVj jV4,Vyi PHONE: CONTRACTOR: _s�q PHONE: 60('017 FIRE PERMIT #: TANK # 39 PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE INSPECTOR: cs�-a add S vV&f-a DATE: -qza& R I N S E RINSED: ❑ YES )4NO METHOD: ---- RINSATE DISPOSAL SITE: ---- MANIFEST #: S OTHER TRACKING #: AMOUNT: -- v A P R PURGED: ❑ YES XNO READINGS AT REMOVAL: METHOD: L.E.L.: 02: COMMENTS*: AMOUNT USED: C . ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZ O OOD ❑ POOR ❑ HOLES Comments*: N S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS XOTHER TOTAL LENGTH OF PIPING T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: pj' jrj� ffj 1p�,C� /ZD SOIL TYPE OBSERVATIOe SAMPLE # T A _ -- N K EXCAVATION SIZE: X _X_.41eQ a� Length Width Depth p -7 IOLf S DEPTH SOIL TYPE OBSERVATION* SAMPLE # A P zft norii o v -.s- M I Off- 1� P Pi i �' o L E %20 O o -r (,IDC I N TRENCH SIZE: X X Length Width Depth G UNDWATER: FT # HOURS SINCE DEWATERING: 2 0 SAMPLING METHOD: OBSERVA ST fl-_ - 40LcYads COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # STOCKPILE#2: Cubic Yards COVERED: ❑ YES ❑ NO__SAM`PTE# SAMPLE# OTHER SAMPLES:-----' LABORATORY: 44vanded 6e ,epom SAMPLERS NAME: CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: �— SITE MAP ATTACHED**:,XYES ❑ NO EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed * Include all comments/observations ** Site Map Required M