Laserfiche WebLink
SAN JOAQUIN CC JNTY ENVIRONMENTAL HEAD,j'H DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: 1--�0(�� VI� , �,� ��p,� ,�/ SR#: 3 <br /> ADDRESS:[ .. ` CITY: <br /> OWNER NAME: Ct Cit PHONE: 333 - 07% <br /> CONTRACTOR: ^Si,� ' �,p F�{a2 : PHONE: S�g I <br /> FIRE PERMIT#: TANK#39 OM y31 13101 S)joS <br /> ❑ PIPING REMOVAL UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: <br /> R RINSED: YES L3NO METHOD: �'iN AMOUNT: I <br /> I <br /> N RINSATE DISPOSAL SITE: T'�— 9i CN 7 0 OTNvom <br /> EMANIFEST#: . OTHER TRACKING#: <br /> V <br /> A PURGED: DYES ❑ NO METHOD: ke AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: c 02: COMMENTS*: <br /> C TANK MATERIAL: STEEL LJFIBERGLASS LJOTHER TANK SIZE aa" 424 <br /> 0 TANK CONDITION: 1f GOOD ❑ POOR ❑ HOLES Comments*: N,, � , CWOS6, <br /> IN <br /> N <br /> S PIPE MATERIAL: ❑ STEEL �,FIBERGLASS LJOTHER TOTAL LENGTH OF PIPIN <br /> T PIPE CONDITION: ,9 GOOD ❑ POOR ❑ HOLES Comments*: qb 6d <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T i2 Le cy d i <br /> A Sj <br /> d <br /> N <br /> EIXCAVATION SIZE: 15 X l�_X `T <br /> K <br /> Length N7dfh Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P 1 C ,k <br /> M <br /> P P <br /> L E <br /> N TRENCH SIZE: 'i X X <br /> Length width Depth l�i(.�7�(J N , <br /> GH DEPTH TO GROUNDWATER: ': FT #HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: Np N� <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES r NO SAMPLE# a SAMPLE# <br /> STOCKPILE#2: Cubic Yards COVERED: 11 YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: Go �TSAMPLERS NAME: <br /> ��Y r <br /> CLOSURE IN PLACE: BACKFILL MI TURE: VOLUME: <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 commentstobservations **Site Map Required <br />