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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: Q SR#: <br />ADDRESS: CITY: <br />oa- <br />OWNER NAME: 4- PHONE: <br />CONTRACTOR: LP, WVA QkA PHONE: <br />FIRE PERMIT #: TANK # 39 Q2S-S-6,4 <br />*PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br />INSPECTOR: Q"k Mew 10 DATE: ` Q - I q -(;Lc) (�-, <br />R <br />I <br />N <br />S <br />E <br />RINSED: ❑ YES ❑ NO METHOD: AMOUNT: <br />RINSATE DISPOSAL SITE: <br />MANIFEST #: OTHER TRACKING #: <br />V <br />A <br />P <br />R <br />PURGED: ❑ YES ❑ NO <br />READINGS AT REMOVAL: <br />METHOD: AMOUNT USED: <br />L.E.L.: 02: COMMENTS*: <br />C <br />TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br />N <br />S <br />PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE: X X <br />Length -Mft Depth <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE # <br />AP <br />so ttd!AC� Qo <br />Iii �J� i i S o -i <br />IRS_ <br />M <br />P <br />P <br />L <br />E <br />I <br />NLength <br />TRENCH SIZE: X X <br />Wdth Depth <br />G <br />H <br />DEPTH TO GROUNDWATER: FT <br /># HOURS SINCE DEWATERING: <br />2 <br />p <br />SAMPLING METHOD: <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />STOCKPILE#2: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />OTHER SAMPLES: <br />LABORATORY: i am, <br />SAMPLERS NAME: Ct <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED**: YES ❑ NO5k mogAk <br />EH 23-0043 (Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all comments/observations ** Site Map Required <br />111 <br />