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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: N �61 SR#: �bR.00+C6 �-�- <br /> ADDRESS: a511-5 'Pct4.erSon -Pass CITY: Tr' <br /> OWNER NAME: }ars I)Ctd- —INLW PHONE: 510 - 60o -3360 <br /> CONTRACTOR: Fie l Sys �s �C)y►,Sul+itn�a PHONE: 510- 6 ++ -u q 4 <br /> FIRE PERMIT#: TANK#39 <br /> ❑ PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: <br /> R RINSED: ❑YES ❑ NO METHOD: AMOUNT: <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES ❑ NO ME THO AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: TEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK COND N: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL A FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: XGOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> Length Wdth Depth <br /> S D DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A ° 34 Cbl WiK Sd lo. NO s ,heti l NO Odor Pe,- kikq, 1. D — -�'8 <br /> M 33'/2' CI wiu, S.I No S1-ainih +No 04c- - ILI <br /> P <br /> L <br /> ITRENCH SIZE: X X <br /> NLength Width Depth <br /> G H DEPTH TO GROUNDWATER: HOURS SINCE DEWATERING: <br /> 2 <br /> p SAMPLING METH OBSERVATION*: <br /> STOCKPILE#1: Cuband OVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: C c YarAV COVERED: ❑YES ❑ NO SAMPLE# _ SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: 5Trq.4us �KV►rO,�meh h G SAMPLERS NAME: '� j <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: *AYES ❑ 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 />