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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: 2CS — — -- - <br /> SR#: 6071 7 22),1 <br /> ADDRESS: L-1 <br /> CITY: <br /> OWNER NAME: PHONE: 9,o9 Qctt gigs <br /> CONTRACTOR: M o C ) {lam_ PHONE: � 7S' <br /> FIRE PERMIT #: O�by TANK #39 (/fie 6178 SO Cp <br /> ❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: ti- 3 -16 <br /> R RINSED: YES L3NO METHOD: 'in L y� AMOUNT: �yGj C <br /> I <br /> .10 <br /> N RINSATE DISPOSAL SITE: — I -7 X A 9 <br /> EMANIFEST#: OTHER TRACKING#: <br /> V PURGED: YES ❑ NO METHOD: DC ` C AMOUNT USED: 330 7 Lb <br /> P /� <br /> D READINGS AT REMOVAL: L.E.L.: 0 02: (S Z�� COMMENTS*: <br /> R <br /> C TANK MATERIAL: ❑ STEEL X FIBERGLASS ❑ OTHER TANK SIZE O op <br /> 0 TANK CONDITION: OGOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL:)i'STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION:sYGOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T AAO -T►� <br /> A <br /> N r' <br /> K <br /> EXCAVATION SIZE: 0 X g�X <br /> ..m. raau <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P <br /> M I _ <br /> P Pno <br /> r Ga <br /> L E L_ I/ a z " c, <br /> TRENCH SIZE: X X <br /> N <br /> G H DEPTH TO GROUNDWATER: __1 aQ FT #HOURS SINCE DEWATERING: I31 <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: S Cubic Yards COVERED: OYES ❑ NO SAMPLE# CW_LL)eS-± SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: OYES O NO SAMPLE# 52'EQSE SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY:au oc c 3 g 01 SAMPLERS NAME: onhC <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: 3�y —T , e���wc`���a VOLUME:®9 <br /> SITE MAP ATTACHED*": YES ❑ NO <br /> EH 23-0043(Rev 5/2212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all commentslobservations **Site Map Required <br />