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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: SR#: <br /> ADDRESS: + CITY: <br /> OWNER NAME: -� PtPHONE: Q ZJ <br /> CONTRACTOR: ��p�Q (%���yUp1, PHONE: <br /> FIRE PERMIT#: TANK#39 <br /> ❑ PIPING REMOVAL " 4UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: — DATE: �— j ' <br /> R RINSED: [ ,YES ❑ NO METHOD: '— � VQO,& gC AMOUNT: <br /> W (AOL <br /> I �n ,, , �-n �_^ l <br /> N RINSATE DISPOSAL SITE: lT�- UWA61 Tram � gs `I v� w�(� '06`3 <br /> EMANIFEST#: OTHER TRACKING#: S <br /> V <br /> A PURGED: YES ❑ NO METHOD: AMOUNT USED: ID ' <br /> P l <br /> R READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> C TANK MATERIAL: OTEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION: ❑ GOOD OOR HOLES Comments*: �& <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING (� <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: �) + <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> i <br /> T /n d <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: _X X _ <br /> Length Widlh Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> A P i <br /> M I <br /> P P <br /> L E <br /> I TRENCH SIZE: X X <br /> N Length Width Depth <br /> GH DEPTH TO GROUNDWATER: FT #HOURS SINCE DEWATERING: <br /> 2 <br /> p SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1: Cubic Yards COVERED: LI YES tNO SAMPLE# SAMPLE# � <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: C,0�j o — SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: Ak yzoj ,�—C Z' GLUME: <br /> SITE MAP ATTACHED**: ES ❑ 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 />