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SAN JOAQUIN COUNTY ENVIRONMENTAL HE ALT DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: <br />ADDRESS: <br />OWNER NAME: <br />CONTRACTOR: <br />FIRE PERMIT #: <br />SR#: O 0 _xbu 4 <br />CITY: Cuc�t' <br />WPHONE: 3`°i-YZ SS <br />N e -u- �) li iEn��d� /Lo`i`� /�So ��a�� PHONE: <br />TANK #39- 0 51('09L� <br />❑ PIPING REMOVAL JW UST REMOVAL <br />LIcMCrTnD. Nn .KiA4r%,� <br />❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />DATE: S( G [ 13 B <br />EH 23-0043 (Rev 52212007) <br />IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentsiobservations ** Site Map Required <br />RINSED: YES LlNO <br />0/ <br />METHOD: Jp LpIS iC.ous <br />AMOUNT: �(J _ <br />R <br />I <br />N <br />RINSATE DISPOSAL SITE: <br />SOTHER <br />MANIFEST M. TRACKING #: <br />E <br />V <br />A <br />PURGED: L3YES ❑ NO METHOD: <br />AMOUNT USED: <br />P <br />0 <br />READINGS AT REMOVAL: L.E.L.: 5 02: 6-7 COMMENTS*: <br />R <br />TANK MATERIAL: )0 STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br />C <br />0 <br />TANK CONDITION: Id GOOD ❑ POOR ❑ HOLES Comments*: <br />S <br />PIPE MATERIAL: P STEEL ❑ FIBERGLASS ❑OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: ❑ GOOD P POOR ❑ HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE# <br />T <br />ri1.A" <br />A <br />N <br />K <br />EXCAVATION SIZE: X X " JJ n.o� Vt4 <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE# <br />A <br />M <br />P <br />I <br />P <br />P <br />L <br />E <br />I <br />TRENCH SIZE: X X Cµtd /� ✓� <br />N <br />vneu DIM <br />G <br />H <br />DEPTH TO GROUNDWATER: 7 O FT <br /># HOURS SINCE DEWATERING: <br />2 <br />O <br />SAMPLING METHOD: <br />/A <br />OBSERVATtiION*: <br />STOCKPILE#t: Cubic Yards COVERED: ❑YES � NO 'SAM .� PLE# <br />STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED*": ❑ YES ❑ NO <br />EH 23-0043 (Rev 52212007) <br />IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentsiobservations ** Site Map Required <br />