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SAN JOAQUIN CGUNTY ENVIRONMENTAL HEA�H DEPARTMENT <br />UST4PIPI14G CLOSURE INSPECTION FORM <br />SITE NAME: <br />ADDRESS: j oj4v ,- Qno zbjP -, StyCl�-ft�� <br />OWNER NAME: <br />CONTRACTOR: <br />SR#: CPQ 12 R <br />CITY: <br />PHONE: <br />PHONE: <br />FIRE PERMIT #: �6cS TANK # 39 <br />X PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: 'am cm R u�Z DATE: --�)/ id/ I q <br />R <br />I <br />RINSED: ❑ YES �eNO <br />METHOD: <br />AMOUNT: <br />N <br />RINSATE DISPOSAL SITE: <br />_ <br />S <br />FEST #: <br />-- <br />OTHER TRACKING M <br />v <br />A <br />P <br />PURGED: ❑ YES NO <br />METHOD: <br />AMOUNT USED: <br />READ S AT RE-MOVAL: <br />L.E.L.: 02: COMMENTS*: <br />C <br />TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER — - <br />I TANK -SIZE <br />0 <br />TANK OM) GOOD ❑ POOR ❑ HOLES Comments*: <br />N <br />S <br />PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ,l -OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH SOIL TYPE <br />OBSERVATION* <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE: X X <br />Length Width Depth <br />S <br />DEPTH <br />SOIL TYPE 3 . t el 4-Ne6DBSERVATION* SAMPLE # <br />A <br />P <br />C t <br />o �14— <br />M <br />I <br />k din, <br />i <br />P <br />P <br />15� i <br />L <br />E <br />� <br />N <br />TR ENCH SIZE: X X <br />Length Wdth Deplh <br />G <br />H <br />DEPTH TO GROUNDWATER: FT <br /># HOURS SINCE DEWATERING: <br />2 <br />0 - <br />SAMPLING METHOD: Haird Qv <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED _C] YES— ❑-146 SAMPLE # SAMPLE # <br />STOCKP Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />OTHER SAMPLES: <br />LABORATORY: Advo-wedGeoemornmoikiSAMPLERS <br />NAME: .K,�, j.4-0 <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: 33�ES ❑ NO <br />EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentslobservations ** Site Map Required <br />