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SAN JOAQUIN C0NTY ENVIRONMENTAL HEASH DEPARTMENT UST/PIPING CLOSURE INSPECTION FORM SITE NAME: ADDRESS: OWNER NAM CONTRACTO SR#: S9ftZM, CITY: �; PHONE: PHONE: FIRE PERMIT M TANK # 39 16 PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE INSPECTOR: � �sr DATE ❑ TEMPORARY CLOSURE R RINSED: ❑ YES NO METHOD: AMOUNT: I N RINSATE DISPOSAL SITE: S E MANIFEST M OTHER TRACKING M P PURGED: ES ❑ NO METHOD: �� ' �� ow,AMOUNT USED:yq 'C R READINGS AT REMOVAL: L.E.L.: ,( 02: COMMENTS*: �}' N(�C(jP Alkla,-,, a,-,, W� C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE 0 TANK CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: N S PIPE MATERIAL: L3 STEEL IBERGLASS L3 OTHER TOTAL LENGTH OF PIPING rf' T PIPE CONDITION: GOOD ❑ POOR ❑ HOLES Comments*: DEPTH SOIL TYPE OBSERVATION* SAMPLE # T A N K EXCAVATION SIZE: X Uno "ft X Dw* S DEPTH SOIL TYPE OBSERVATION* SAMPLE # A P S ,o ^t1� M I i N ov 'gni i— P p rl L E I N TRENCH SIZE: XX NO G H DEPTH TO GROUNDWATER: FT # HOURS SINCE DEWATERING: 2 0 SAMPLING METHOD: OBSERVATION*: STOCKPILE#1: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # STOCKPILE#2: Cubic Yards COVERED: ❑ YES ❑ NO SAMPLE # SAMPLE # OTHER SAMPLES: LABORATORY: ? fi SAMPLERS NAME: , CLOSURE IN PLACE: BACKFILL MIXTURE: VOLUME: SITE MAP ATTACHED**: ES ❑ NO EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed * Include all comments/observations ** Site Map Required