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E <br />G <br />E <br />N <br />E <br />R <br />A <br />L <br />APPLICATIONiFOR PERNIT�i�tK SAN JOAWIIN LOCAL HEALTH DISTRICTS <br />Fit it 91 Utt it att 141 it. <br />%u �/;" #r" /# 5 Cc*, v 1 <br />AP <br />SJLHD - UNDEIV. tOUND 'TANK CLOSURL•'/ABANDOtartx,N'T INSVECTIUN <br />(SHADED AREA -TO DE FILLED IN FOR THE FIRST TANK ONLY) <br />i J11L' 1�,1\I"Ili <br />l d/iF. <br />G1a/�v <br />- -1 <br />Sp,✓rcE' LC- <br />11VV,I1. .1 <br />/r /4 4Ja,'.�er/q <br />5/ock/on <br />OWNER NAME <br />L u/ G' <br />Ju wKe Ca , <br />OWNER PHONE q ` JU9 t�� y _� 3 <br />P <br />/(Go <br />E. Lu `u e«� <br />CONTRACTOR <br />Jim <br />7%,os�e Ui/ <br />CON. PHONEq �aoSJ /fid- yS8/ <br />i SJLHD PERMIT q I EPA 10,4CvxorFIRE PERMIT q /,) o -d y <br />INSPECTOR earo/ Oz DATE <br />R RINSED (Ye METHOD <br />I <br />IJ RINSATE DISPOSAL SITE '�;l1 /e 1, <br />S Cc• 4LO <br />E MANIFEST <br />TANK q 39 - 2oz 73 - - SZ_ <br />RINSE AMOUNT <br />-OR- OTHER <br />DRAW SITE MAP ON FtPVSRSE' <br />1'11 2:1 04:1(7/38) <br />V <br />A <br />VAPORS PURGED YA) <br />METHOD/ (ce <br />AMOUNT USED <br />P <br />L.E.L. READING AT REMOVAL (MUST BE < 20%) <br />0 <br />T <br />R <br />COMMENTS <br />A_ <br />N <br />TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br />TANK SIZE <br />K <br />C <br />/ <br />0 <br />TANK CONDITION GOOD, POOR, HOLES) <br />P <br />N <br />I <br />S <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br />q FEET <br />P <br />T <br />I <br />PIPING CONDITION (GOOD, POOR, HOLES) ti0r� <br />N <br />G <br />DEPTH <br />SOIL TYPE <br />OBSERVATION <br />SAMPLE 9. <br />T <br />I <br />N <br />E <br />K <br />L <br />D <br />EXCAVATION SIZE: X 7 X <br />YDS OF SOIL: <br />s- <br />I <br />A <br />DEPTH <br />SOIL TYPE <br />OBSERVATION <br />SAMPLE q <br />N <br />M <br />P <br />S <br />P <br />I <br />Srr. cl cl <br />A-10 ; 1 <br />P <br />L <br />P <br />E <br />I <br />E <br />C <br />N <br />T <br />C <br />TRENCH DIMENSION X _ X <br />YDS OF SOIL <br />I <br />0moDEPTH <br />TO G.W.: FT <br />SAMPLING METHOD <br />N <br />N OF HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />UF_o�[ <br />LABORATORY: 1 _v1 oll_�lp <br />SAMPLERS NAME:`O/��e�t <br />CLOSURE IN PLACE I MIXTURE: <br />VOLUME: <br />DRAW SITE MAP ON FtPVSRSE' <br />1'11 2:1 04:1(7/38) <br />