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00 00 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITENAME: CHeVROO &�42QIIJ SRI <br />ADDRESS: 'ISS S-IDUTtj 'TPAk,-( SWO, CIT <br />OWNERNAME: CfAC-vRoN PRovucfs Co. PHON <br />• <br />CONTRACTOR: I NC. PHONE: q23,551 '7555 <br />FIRE PERMIT #: Vb -OlTANK # 39 N/() <br />W PIPING REMOVAL Ll UST REMOVAL L3 CLOSURE IN PLACE L3 TEMPORARY CLOSURE <br />INSPECTOR: IBC -Try t+O , DATE: MARCH 21® <br />R <br />1 <br />RINSED: U YES NO <br />METHOD:' ALL <br />AMOUNT: G U 0c, i- P1, <br />N <br />S <br />E <br />RINSATE DISPOSAL SITE: <br />MANIFEST M S OTHER TRACKING M <br />V <br />A <br />p <br />0 <br />R <br />Ll <br />PURGED: YES L3 NO <br />READINGS AT REMOVAL: <br />METHOD: AMOUNT USED: <br />L.E.L.: 02: COMMENTS*: <br />C <br />TANK MATERIAL: L3 STEEL L3 FIBERGLASS L3 OTHER <br />TANK SIZE <br />0 <br />TANK CONDITION: L3 GOOD L3 POOR L3 HOLES Comments*: <br />N <br />S <br />PIPE MATERIAL: E3 STEEL [3 FIBERGLASS L3 OTHER <br />TOTAL LENGTH OF PIPING <br />T <br />PIPE CONDITION: L3 GOOD E3 POOR L3 HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE# <br />T <br />A <br />N <br />EXCAVATION SIZE: X X <br />Length Width De* <br />$ <br />DEPTH <br />SOIL TYPE OBSERVATION* SAMPLE# <br />A <br />P <br />siii-i <br />M <br />1 <br />6 j LTy'SANF,) Ntep OQ3W t4 ��j Ot%'POW VWY %L' (d I_ I jq) <br />P <br />P <br />3jP-j18tL;TYW <br />mEDBQpNgl\AOISFFOWDVAZTWi-td6,P,V2),D-3 <br />L <br />E'3,50SILW:5"N <br />bqq�NN-MQISMWPWSNL.0�1��A <br />I <br />N <br />TRENCH SIZE: x --(a4x -V+- <br />Le,.. Width D.M� <br />GIDEPT <br />0 GROUNDWATER: --N/A FT <br /># HOURS SINCE DEWATERING: N/A <br />SAMPLING METHOD: R/A <br />OBSERVATION*: t4/x <br />STOCKPILE#1: Cubic Yards COVERED: U YES 0 NO SAMPLE# SAMPLE# <br />STOCKPILE#2: Cubic Yards COVERED: U YES L3 NO SAMPLE# SAMPLE# <br />OTHER SAMPLES: Qoc./ F W?, GMcA<PU-F- iG Cov6P-60 (�3. toS CUN& YAIZ'Pg <br />LABORATORY: <br />MCCAM BC -LL ANA CYTI CAL L4 SAMPLERS NAME: f -RIC CftDOROFfr- <br />CLOSURE IN PLACE: <br />I BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED":�(YES L3 NO <br />I � <br />EH 23-0043 (Rev 5/22/2007) <br />01 <br />PAG6 i of L <br />IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all comments/observations I Site Map Required <br />