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SAN JOAQUIN CCf JNTY ENVIRONMENTAL HEAL.-r'H DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: ( t t mfaAAkcia SR#: 00 6 600 <br /> ADDRESS: '����f niw�� , �T N/I G�✓A I C_ C e CITY: <br /> OWNERNAME: G}v� nlQCl�i PHONE: <br /> CONTRACTOR: �n �Z�YD�Owvr Cen CM�[�2Ey� PHONE: � 79- 693�F <br /> FIRE PERMIT #: TANK#39 <br /> ❑ PIPING REMOVAL ;' UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: f" I LI Ivc DATE: ��c�� I I <br /> R KM <br /> : VYES ❑ NO METHOD: P t AMOUNT: 4 q Q VA <br /> II� --�� -- 11 - <br /> N E DISPOSAL SITE: 2►p0 Ajwrr�AK S 2Z Z <br /> E ST#: ©O QIP �O�2S3 lL OTHERTRA ING#: <br /> A PURGED: *YES L3NO METHOD: AMOUNT USED: <br /> P <br /> a READINGS AT REMOVAL: L.E.L.: O 02: /�,CF COMMENTS': & � � <br /> C TANK MATERIAL: � STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> N TANK CONDITION: L1GOOD I$f POOR X HOLES Comments*: f <br /> �� hp� �6 <br /> S PIPE MATERIAL: 10 STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING Ff Cw,4t, 4Ar <br /> T PIPE CONDITION: �kGOOD L3POOR L3HOLES Comments': <br /> DEPTH SOIL TYPE OBSERVATION' SAMPLE# <br /> T F SaM 52 <br /> A 3 <br /> N <br /> K <br /> EXCAVATIONSIZE: X X_2�Ef <br /> WO v <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 tau am upx <br /> GDEPTH TO GROUNDWATER: FT 7#HOURS SINCE DEWATERING: FAIA <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION': <br /> STOCKPILE#1: 10 -CubicYards COVERED: AYES ❑ NO SAMPLE# 5;I STIC SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: WES ❑ NO SAMPLE# sU-ST{l SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE: I BACKFILL MIXTURE: J VOLUME: <br /> SITE MAP ATTACHED":'§kYES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> 'Include all commentsiobservations "Site Map Required <br />