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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: Country Marketplace SR#: SR0078652 <br /> ADDRESS: 1789 W. Charter Way CITY: Stockton <br /> OWNER NAME: Harjinder Bhade PHONE: 408-410-4011 <br /> CONTRACTOR: Franzen Hill PHONE: 559-688-2977 <br /> FIRE PERMIT#: TANK#39 <br /> ❑X PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: Cesar Ruvalcaba DATE: 04/20/2018 <br /> R RINSED: ❑YES ❑x NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES ❑ NO METHOD: AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS I@ OTHER TOTAL LENGTH OF PIPING Approximately 35 feet <br /> T PIPE CONDITION: 0 GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A► P —3.5' Sample taken on 04/05/2018 SS1 <br /> M 1 —3.5' Sample taken on 04/09/2018 SS3 <br /> P p <br /> L E <br /> I TRENCH SIZE: 3 X 4 X 3 <br /> N Length Width Depth <br /> GH DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY:Sun Star Laboratories Inc. SAMPLERS NAME: Mathew Rosman <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 />