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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM / <br /> SITE NAME : SR#: aI � 7C) C <br /> ADDRESS: � � I 'ff } j� /II ? �� ��1 (u CITY: , r <br /> OWNER NAME : 7 5 f PHONE: a <br /> � � � �• `�� <br /> CONTRACTOR: U t () L 'I PHONE: <br /> FIRE PERMIT #: TANK # 39 <br /> OWING REMOVAL b IIST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: t j' C - DATE: <br /> R RINSED: BYES ❑ NO METHOD: A� AMOUNT: <br /> N RINSATE DISPOSAL SITE: <br /> S OTHER TRACKING #, <br /> E MANIFEST #: <br /> V a� AMOUNT USED: <br /> A PURGED: 6�fJYES ❑ NO METHOD: Ll i Cu <br /> P ` L <br /> D READINGS AT REMOVAL: L.E.L.: 02: COMMENTS*: <br /> R <br /> C TANK MATERIAL: `) STEEL LJ FIBERGLASS ❑ OTHER TANK SIZE ) r <br /> 0 TANK CONDITION: LlGOOD L3POOR HOLES Comments*: Co�+Uc ��� (31S' <br /> N <br /> S PIPE MATERIAL: TEFL LJ FIBERGLASS Ll OTHER TOTAL LENGTH OF PIPING . Ff <br /> T PIPE CONDITION: El GOOD POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> r t <br /> T / k 4a _ UC/ c a. of ' VLD i r1 i X12 r �� `zCp YI <br /> A i fv ,. „ oda ( <br /> N , . <br /> K <br /> EXCAVATION SIZE: ) 7 X Cdx <br /> ffi <br /> S rDEH SOIL TYPE OBSERVATION* SAMPLE # <br /> I <br /> P P <br /> L E <br /> SIZE: XIX I � <br /> N WIdN D th <br /> G H DEPTH TO GROUNDWATER; \i ( _ T # HOURS SINCE DEWATERING: <br /> 2 <br /> 0 SAMPLING METHOD: OBSERVATION*: <br /> STOCKPILE#1 : irk Cubic Yards COVERED: IXYES ❑ NO SAMPLE # SAMPLE # <br /> STOCKPILE#2: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES: <br /> LABORATORY: q i ` .. 1 SAMPLERS NAME: <br /> CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: <br /> SITE MAP ATTACHED YES ❑ NO <br /> EH 2M043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br /> * Include all commentslobservations ** Site Map Required <br />