Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: �i�C�P/VI SR#. <br /> ADDRESS: 2 5 U LA C ud� ,S�[,�L U� CITY: (;to C- 6O <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: vj Lky Ak _ n C PHONE: <br /> FIRE PERMIT#: ,Q rf�g113 (2wt. 51�Q TANK#39 Sc) Q 3 <br /> ❑ PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPO k SURE <br /> INSPECTOR: W DATE: <br /> R RINSED: YES ❑ NO METHOD. ( AMOUNT: ©( MS <br /> I <br /> N RINSATE DISPOSAL SITE: V\tAUCS <br /> E MANIFEST M 03 C`f 3� � OTHER TRACKING M <br /> A PURGED: ❑YES ❑ NO METHOD: Df vAMOUNT USED: 1,30 l <br /> P <br /> READINGS AT REMOVAL: L.E.L.: 0 02: Z O 0►/ COMMENTS*:M�r ver. �`� _IV reckoll-j; 9P �J <br /> R . �'v S t4tct l'� A ^�K v le-ck �l LEC t C <br /> f <br /> C TANK MATERIAL: A,STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 6 <br /> 0 TANK CONDITION: ' GOOD ❑ POOR ❑ HOLES Comments*: °C ,T" Px <br /> S PIPE MATERIAL: ❑ STEEL 96FIBERGLASS ❑ OTHER I TOTAL LENGTH OF PIPING Q <br /> T PIPE CONDITION: *GOOD ❑ POOR ❑ HOLES Comments*: N U N1 <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T . S $ C 2 w a S CS) xW� - 9. <br /> - <br /> A Of c c( s -i5 -Ti''f-MN sj c(� orb f s `t 2' <br /> K <br /> EXCAVATION SIZE: X X 13 <br /> Length--'With Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> AP 3�' . s� e�+-a (�� 3.5 <br /> M I 3,51k ; a <br /> P p <br /> L E <br /> 1 TRENCH SIZE: X X <br /> N Length Width Depth <br /> G , H DEPTH TO GROUNDWATER: 13'.WT T #HOURS SINCE DEWATERING: JV O ?LvJ <br /> 0 SAMPLING METHOD: �p x � 0 OBSERVATION*: � q,�t vel .per( A. �r <br /> STOCKPILE#1: d Cubic Yards COVERED: ❑YES NO SAMPLE# S �P� SAMPLE# S t� S <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: l �. SAMPLERS NAME: �Tk <br /> CLOSURE IN PLACE: BA KFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**:AYES ❑ NO <br /> o <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentsiobservations **Site Map Required . <br />