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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE NAME: ADDRESS: OWNER NAM UST/PIPING CLOSURE INSPECTION FORM SR#: CITY: (AGU PHONE: 3bej- 2�-2S - CONTRACTOR: Nad 0 Wt1d � Sad � PHONE: 0 3%0 FIRE PERMIT #: TANK # 39 0 5 �b 0.55 ❑ PIPING REMOVAL I IUST REMOVAL El CLOSURE IN PLACE Ll TEMPORARY �CLOSURE irucoGrrnR• VI • NLIAr lit DATE: :& f l5 EH 23-0043 (Rev 5122/2007) IMPORTANT NOTES: Complete one form for each tank removed * Include all commentslobservations ** Site Map Required AMOUNT: R RINSED: YES ❑ NO n I N RINSATE DISPOSAL SITE: S E Y A 7METHOD: MANIFEST #: OTHER TRACKING M PURGED: ❑ YES ❑ NO AMOUNT USED: P 0 R C READINGS AT REMOVAL: L.E.L.: �� 02: / COMMENTS*: TANK MATERIAL: STEEL ❑FIBERGLASS ❑OTHER TANK SIZE 3 0 TANK CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: N S PIPE MATERIAL: d STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING T PIPE CONDITION: ❑ GOOD /d POOR ❑ HOLES Comments*: DEPTH SOIL TYPE OBSERVATION* SAMPLE # T A NIA) N K EXCAVATION SIZE::XX oX µ S DEPTH SOIL TYPE OBSERVATION* SAMPLE # A M P I P P L E I N TRENCH SIZE: X X L -P MM oau G H DEPTH TO GROUNDWATER: /7D FT # HOURS SINCE DEWATERING: 2 p SAMPLING METH D: A_ /'�Vt OBSERVATION*: STOCKPILE#1: Cubic Yards COVERED: OYES FIN SAMPLE # SAMPLE# STOCKPILE#2: Cubic Yards COVERED: DYES ❑ NO SAMPLE# SAMPLE# OTHER SAMPLES: LABORATORY: SAMPLERS NAME: CLOSURE IN PLACE: I BACKFILL MIXTURE: VOLUME: SITE MAP ATTACHED**: ❑ YES ❑ NO EH 23-0043 (Rev 5122/2007) IMPORTANT NOTES: Complete one form for each tank removed * Include all commentslobservations ** Site Map Required