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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITENAME : San 3eact, �; n QyyJionh � I �S � p ;s } r, � SR#: ,jg00783$3 <br /> ADDRESS : CITY: 540CILfin <br /> OWNER NAME : 5U� 70 ^ ham n og *� � 3'. k Q31r,�� PHONE : a 01 Lftil' 6 (,7d- <br /> CONTRACTOR: 3olePln Q y PHONE : L101) 30� 5`Id <br /> FIRE PERMIT #: —� TANK # 39 <br /> lI PIPING REMOVAL O UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: ZowN AltnnZ DATE : L / Vlot% <br /> R RINSED: ❑ YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST P OTHER TRACKING M <br /> v <br /> A PURGED: ❑ YES L3NO METHOD: AMOUNT USED: <br /> P <br /> D READINGS AT REMOVAL: L.E.L. : 02: COMMENTS*: <br /> R <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> O TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> L.neu Ni% oaf <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> A P I L 1 50%MPIX. wgk& tw undfr w� * <br /> M 1 rt^o rp A io ; w h ��s J <br /> P P <br /> L E <br /> TRENCH SIZE: ( in X ).4 ^ X 1 In <br /> N 11 vmm nam <br /> G DEPTH TO GROUNDWATER: FT # HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1 : Cubic Yards COVERED: OYES ❑ NO SAMPLE # SAMPLE # <br /> STOCKPILE#2: Cubic Yards COVERED: OYES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES: <br /> LABORATORY: SAMPLERS NAME: (Z M r <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: ❑ YES ❑ NO <br /> EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES : Complete one form for each tank removed <br /> Include all comments/observations ** Site Map Required <br />