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SAN JOAQUIN CCINTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: vl if C , W -� ay e-,., SR#:(d 4 -j") 9 <br />ADDRESS: /e701 St F7 L"dc� Sf-, CITY: Stc>c%.tor) <br />OWNER NAME: W obo- W�2aid-4 PHONE: 000-410 <br />CONTRACTOR:PHONE: <br />FIRE PERMIT #: TANK # 39 Debij6/2- <br />❑ PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE J, TEMPORARY CLOSURE <br />INSPECTOR:Gf� �� �, �� DATE: Z4, //z <br />R <br />RINSED:YES ❑ NO <br />METHOD: <br />AMOUNT: f c'CU l77 <br />N <br />RINSATE DISPOSAL SITE: <br />1M C6- O��A <br />EMANIFEST <br />#:l� <br />OTHER TRACKING #: <br />�----- <br />A <br />P <br />R <br />PURGED>I YES ❑ NO <br />READINGS AT <br />METHOD: AMOUNT USED: (J Q (L -2 S <br />L.E.L.: I 1 '?,, 02: COMMENTS*: <br />C <br />TANK MATERIAL: STEEL ,'FIBERGLASS t�OTHERC�L /JKSI <br />TANK SIZE Ob <br />0 <br />TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: Ur k r o ,&n <br />S <br />PIPE MATERIAL: ❑ STEEL ,FIBERGLASS ❑ OTHER <br />TOTAL LENGTH OF PIPING f Lid ��?cTi�m <br />T <br />PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: tU? kp j <br />DEPTH <br />SOIL TYPE <br />OBSE VATION* <br />SAMPLE # <br />T <br />A <br />N <br />K <br />EXCAVATION SIZE: X]I- X <br />Length NAdth <br />$ <br />DEPTH <br />SOIL TYPE OBSERVATION* <br />SAMPLE # <br />A <br />P <br />M <br />I <br />P <br />P <br />L <br />E <br />I <br />N <br />TRENCH SIZE: X X <br />Longth W th Depth <br />GH <br />DEPTH TO GROUN ATER: FT <br /># HOURS SINCE DEWATERING: <br />2 <br />p <br />SAMPLING ME OD: <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />STOCKPIL 2: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # <br />0TH SAMPLES: <br />L BORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE: <br />BACKFILL MIXTURE: N <br />VOLUME: <br />SITE MAP ATTACHED**: ❑ YES ❑ NO f <br />EH 23-0043 (Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentsiobservations ** Site Map Required <br />