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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/ PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : c2 '+, A ( � SR# 1 <br /> ADDRESS : 1 R , f 'f' ► n�(,1 ,� b�' CITY : <br /> OWNER NAME : 1; 0ha, tQt✓ ` l �� PHONE ( 5) � qy 1— &43 <br /> CONTRACTOR : C.O� C,� -eu gg�, � S , _ PHONE : wo (G � I - <br /> FIRE PERMIT # : r ik TANK # 39 <br /> PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : �, �( X) DATE : <br /> R RINSED : 1 YES ❑ NO METHOD : AMOUNT : <br /> I <br /> N RINSATE DISPOSAL SITE : <br /> S <br /> E MANIFEST # : OTHER TRACKING M <br /> V <br /> A PURGED : XYES ❑ NO METHOD : AMOUNT USED : <br /> P <br /> R READINGS AT REMOVAL : L . E . L . : 02 : COMMENTS* : <br /> fob C TANK MATERIAL : ElSTEEL FIBERGLASS LlOTHER TANK SIZE <br /> N �J 0 TANK CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments* : <br /> N <br /> S PIPE MATERIAL : E3 STEEL L3 FIBERGLASS L3 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 /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> A P In - u 5acu I <br /> M I CGtd,G <br /> P P <br /> L E <br /> I TRENCH SIZE : X X <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER : FT # HOURS SINCE DEWATERING : f� <br /> 2 <br /> p SAMPLING METHOD : OBSERVATION * : <br /> STOCKPILE#1 : Cubic Yards COVERED : ❑ YES W(NO SAMPLE # SAMPLE # <br /> STOCKPILE#2 : Cubic Yards COVERED : ❑ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : <br /> LABORATORY, SAMPLERS NAME : a,{r a ro QfL <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED** : YES ❑ NO <br /> EH 23-0043 (Rev 512212007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all comments/observations ** Site Map Required <br />