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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING` CLOSURE INSPECTION FORM <br /> SITE NAME: �j�- �ssceA s /-rose .. 1 SR#: o c>6" 3G <br /> ADDRESS: (00, 00 CITY: 1 - <br /> OWNER NAME: � 4 �PHONE: Zf h/-- 6 %-/49 <br /> CONTRACTOR: PHONE: L_-6/• 6337 _ <br /> FIRE PERMIT #: TANK#39 MIA <br /> ❑ PIPING REMOVAL ❑ UST REMOVAL CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: �'�r, �-/�" [ /c �9 � <br /> DATE: <br /> R RINSED.>VYES ❑ NO METHOD: ±Ptd an k ry��) f'7f4 344u--JAMOUNT: 3X SS <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES ❑ NO METHOD: A AMOUNT USED: <br /> P <br /> a READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER E 1✓1g4 <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: -j <br /> S PIPE MATERIAL: ❑ STEEJi�FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING 7f71;1 x -2— <br /> T T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: C,40y4 ; Iq <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: XX <br /> �m Baa DWM <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N 11vnan <br /> G H DEPTH TO GROUNDWATER: A&2 FT #HOURS SINCE DEWATERING: (� G <br /> 2 <br /> p 1 SAMPLING METHOD: IVIA OBSERVATION*: <br /> STOCKPILE#1: 2 Cubic Yards COVERED>. ;�YES O NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: d 1A <br /> LABORATORY: C -7r,�,J_ y ,^� 1 1 SAMPLERSNAME: 6r// GfH¢ <br /> CLOSURE IN PLACE: I BACKFILL MIXTURE: awl VOLUME: <br /> SITE MAP ATTACHED*": ES ❑ NO <br /> EH 23-0043(Rev 5/22J2007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required <br />