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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL—TH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITENAME: lAr+& gMi/Vr B¢•IG/ �C (� ne4A ;01 SR#: 2/e4 <br /> ADDRESS: 2(p S/ S 4ir"o9Lr� CITY: y10&z4*j <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: r=Tl<, 15^5f-4gRt T4., <br /> Al N�Gt'�-I PHONE: ZS 602--41 <br /> FIRE PERMIT #: TANK # 39 - -, / 7 <br /> X PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: 2a VGADATE: <br /> R RINSED: YES NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES 1XNO METHOD: AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TA MATERIAL: ❑ EEL ❑ FIB GLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ G039D ❑ POOR HOLES Commen *: <br /> N <br /> S PIPE MATERIAL: X STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TY M OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVA SIZE: X X <br /> v*an aw <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P 2 C Riyb ODon r- iSGn or i P <br /> M 1 1 G r • n <br /> P P <br /> L E <br /> ( TRENCH SIZE: I S X�_.X <br /> N <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#t: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: &4 C C((�0 �A rti SAMPLERS NAME: L S,\[e- <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED": 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 />