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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM / <br /> SITE NAME: 1/� TaZ Lu n:v 'l) M A-aT SR#: 90 78 7 96 <br /> ADDRESS: -� 15, C • w 4T 69 Lu D R� CITY: $]oCK I D nI <br /> OWNER NAME: pz u P I Q A b D A PHONE: �Lu q- q,q- 8735 <br /> CONTRACTOR: fLITE CD n(112A C b-1ZS PHONE: a09- 46163 <br /> FIRE PERMIT#: (-a{IUtV TANK # 39 <br /> � Pa?MFGREMOVAL L3 UST REMOVAL ❑ OSURE IN PLACE Ll TEMPORARY CLOSURE <br /> 1NSPECTOR: -IDIre"I'al- �, � -� DATE: )-q- .ala/ <br /> R RINSED: ❑YES NO METHOD: 1,1k AMOUNT: A/A <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST NA OTHER TRACKING#: <br /> V <br /> A PURGED: ❑YES NO METHOD: A _ AMOUNT USED: <br /> N <br /> P A <br /> R READINGS AT REMOVAL: L.E.L.: NA- 02: A �+ COMMENTS*: Nq fic j wm r <br /> C TANK MATERIAL: ❑ STEEL ❑ FI GLASS ❑ OTHER TANK SIA <br /> 0 TANK CONDITION: ❑ GOOD POOR ❑ HOLES Comments*: <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER XOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES C ments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> u g% vnm o <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A a e ' P C Or Ln(v �Yz <br /> M I " NC- r 3 v <br /> P I rb s PH1p, o o ✓ b <br /> 5' s V 94 e 060 - 8 <br /> I JDC TRENCH SIZE: X A X <br /> N u Waa <br /> G H DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: 79- <br /> 0 SAMPLING METHOD: A/A OBSERVATION*: IVA <br /> STOCKPILE#1: Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> STOCKPILE#2: k Cubic Yards COVERED: OYES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: 1V/- <br /> LABORATORY: ,dQ0 U V V. SAMPLERS NAME: ' a,rd R <br /> (� <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: I✓A VOLUME: <br /> SITE MAP ATTACHED**: AIYES ❑ NO <br /> EH 23-0043(Rev 5/2212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all comments/observations *"Site Map Required <br />