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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: Le— SR#: ��o9G2�o0 <br /> ADDRESS: o9Z{0/ , QOJ- �d, CITY: cf7`i7C/c D/7 <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: Li PHONE: (Zoq)g32-O(QC7fp <br /> FIREPERMIT#: Mgr PzLLwcLF-, D. c9yl lji4ci TANK#39 <br /> ❑ PIPING REMOVAL 0 UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: CG " i v2 rv--,, DATE: 0/// 114 � ,/2//� <br /> R RINSED: YES ❑ NO METHOD: -rrj je riY"Sc. AMOUNT: C0c:50 5CLQ . <br /> I <br /> N RINSATE DISPOSAL SITE: bl< - Di XU Yj -1 30 O W cV1'tin W ax&2 -z>'j k o n Oiq <br /> E MANIFEST#: C)0Z� �j��sa�F OTHER TRACKINGM <br /> E <br /> A PURGED: YES ❑ NO METHOD:Tw-t l CQ� AMOUNT USED:/CFO /&S. <br /> P <br /> JJ <br /> R READINGS AT REMOVAL: L.E.L.:0.0% 02: ,q j COMMENTS VV;VneSSe of to rE). <br /> C TANK MATERIAL: .Y%.STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 12 ,O n O <br /> 0 TANK CONDITION:..GOOD ❑ POOR ❑ HOLES Comments*:Ol,t,Icr Coaby1 it ckt i p pe,, of-f M S OtS <br /> N <br /> S PIPE MATERIAL: Ll STEEL ;FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING Unlcnou>n y ENax ta"n -fit <br /> T PIPE CONDITION: ",,GOOD ❑ POOR ❑ HOLES Comments*: pj ll]2S Yl (fid U &LLn'n6j kX0CV <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: 36 X -.O-t. X 1 <br /> wm <br /> vowm <br /> SDEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A <br /> M <br /> P <br /> L E <br /> I TRENCH SIZE: X X <br /> N u*m Mft o�m <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> SAMPLING METHOD: OBSERVATION`: <br /> STOCKPILE#7: Cubic Yards COVERED: ❑YES XNO SAMPLE#Sp/' / SAMPLE# / Z <br /> STOCKPILE#2: X50 CubiCYards COVERED: ❑YES )KNO SAMPLEkDe2-L 61022 SAMPLE#&F9--3.,SP2-*{, 2-57 <br /> OTHER SAMPLES: s <br /> LABORATORY: Cat 71e a-G - SAMPLERS NAME:wi6&&tM <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**:)",VES ❑ NO <br /> EH 23-0043(Rev 5/2212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> IL h�( (nD4)� Include all comments/observations **Site Map Required <br /> 'Tan <br />