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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : Q,vt �� SR# : <br /> ADDRESS : �" S a c r K.m Jwv S CITY : Loci I � <br /> OWNER NAME : LAti iq c ci PHONE : <br /> CONTRACTOR : C. I � EVA � � / �, �i .rS / 411 PHONE : .201 Lf • yfoo <br /> FIRE PERMIT # . TANK # 39 D � S <br /> ❑ PIPING REMOVAL Cl UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : 1 " �>� NJ DATE . i t ' I0 I Y <br /> R RINSED : ❑ YES ❑ NO METHOD : AMOUNT : <br /> I <br /> N RINSATE DISPOSAL SITE : <br /> S <br /> E MANIFEST # : OTHER TRACKING # : <br /> V <br /> A PURGED : ❑ YES ❑ NO METHOD : AMOUNT USED : <br /> P <br /> R READINGS AT REMOVAL : L . E. L . : 02 : COMMENTS* : <br /> C TANK MATERIAL : ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> 0 TANK CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments* : <br /> N <br /> S PIPE MATERIAL : ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> T ( C <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE : S X X <br /> Length Width Depth <br /> S DEPTH SOIL TYPE 0 ERVATION * SAMPLE # <br /> A P <br /> M I <br /> P P <br /> L E <br /> I TRENCH SIZE : X X <br /> N Length Width Depth <br /> G H DEPTH TO GROUNDWATER : FT # HOURS SINCE DEWATERING : <br /> 2 <br /> p SAMPLING METHOD : OBSERVATION* : <br /> STOCKPILE#1 : Cubic Yards COVERED : LI YES 5fNO SAMPLE # S / SAMPLE # <br /> STOCKPILE#2 : Cubic Yards COVERED : ❑ YES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : i <br /> LABORATORY : N� � C 1 L (,� Y'�4 fw� SAMPLERS NAME : ,J i I U I � , K v� <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED** : Uf YES ❑ NO <br /> EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all commentslobservations ** Site Map Required <br />