Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: 7 - _9-le SR#: <br /> ADDRESS: CITY: <br /> OWNER NAME: PHONE: <br /> CONTRACTOR: IAA) PHONE: <br /> FIRE PERMIT#: � � ANK#39 ����� � <br /> PIPING REMOVAL UST REMOVAL El CLOSURE IN PLA E ❑ TEMPORARY CLOSURE <br /> INSPECTOR: ��- -- DATE: (azlq z <br /> R RINSED: PLYES ❑ NO METHOD: ti, AMOUNT: 400) oma <br /> I n <br /> N RINSATE DISPOSAL SITE: D� me 1� o -06n 000 . p� <br /> EMANIFEST#: U 103 C16OTHER TRACKING#: <br /> APURGED:'OYES ❑ NO METHOD: AMOUNT USED: rt1vy� b <br /> P � <br /> READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: QtrWV�—� ,�R r � ~� err , so <br /> C TANK MATERIAL:ASTEEL ❑ FIBERGLASS OTHER W 2%,A 8 TANK SIZE ��n(-? i <br /> 0 TANK CONDITION: 'GOOD ❑ POOR ❑ HOLES Comments*: No K5 o-r Y-A. Z�Cv� ate, <br /> N <br /> S PIPE MATERIAL: ❑ STEEL §i FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION:tU& GOOD ❑ POOR ❑ HOLES Comments*:,!e— 'Aa <br /> DEPTH SOIL TYPE OBSERVATION* Y'� a o SAMPLE# <br /> T 5 2Z >; C 2- K S eS -1 s ( C W :J -'� >5 <br /> A 9. st. 4 <br /> N W41z <br /> K <br /> EXCAVATION SIZE: X 3 X 13 <br /> Length Width Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> M P S` ? c� a �, `- D if ow+ D I , <br /> S- r <br /> (omae I - 3S <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER: r FT #HOURS SINCE DEWATERING: /V, (gyp„jc,- Vyq <br /> 2 <br /> 0 SAMPLING METHOD: VOA j- Lt` 1AI j OBSERVATION*: �°dJ ,C ,tV-, n d LOSMI: <br /> e> blrSTOCKPILE#1: tb CubicYards COVERED: ❑YES 0 SAmPEE-# AMPLE!l r <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: �- �I (- SAMPLERSNAME: S -&nA-,0C C6.►n <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> f <br /> EH 23-0043(Rev 5122/2007) IMPORTANT NOTES:Complete one form for each tank removed <br /> *Include all commentstobservations **Site Map Required <br />