Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/ PIPING CLOSURE INSPECTION FORM n , n <br /> SITE NAME : d lw r o �\ � (0 � � SR# : O&A V <br /> ADDRESS : tilQ � (� , nMu.Lr• CITY : <br /> OWNER NAME : PHONE : <br /> CONTRACTOR : I > au , PHONE . <br /> FIRE PERMIT # : TANK # 39 <br /> IPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : Vl( ,� � DATE . <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 LJNO METHOD : AMOUNT USED : � - <br /> P <br /> R READINGS AT REMOVAL : L. E . L. : 02 : COMMENTS* : N � <br /> � 0 C TANK MATERIAL : ❑ STEEL FIBERGLASS ❑ OTHER TANK SIZE <br /> ' 0 TANK CONDITION : 1 , GOOD ❑ POOR ❑ HOLES Comments* : <br /> N <br /> S PIPE MATERIAL : ❑ STEEL LJ FIBERGLASS OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments* : <br /> DEPTH SOIL TYPE OBSERVATION * SAMPLE # <br /> A t,L{.l" <br /> N <br /> K <br /> EXCAVATION SIZE : X X <br /> Length NO Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> M P s s <br /> P P <br /> L E <br /> I TRENCH SIZE : X X <br /> N Length Width Depth <br /> GH DEPTH TO GROUNDWATER : FT # HOURS SINCE DEWATERING : AIA <br /> 2 A / <br /> O SAMPLING METHOD : OBSERVATION * : / v <br /> STOCKPILE#1 : Cubic Yards COVERED: YES Ll NO SAMPLE # SAMPLE # <br /> STOCKPILE#2 : Cubic Yards COVERED : ES ❑ NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : <br /> LABORATORY : SAMPLERS NAME : y� <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : N/ VOLUME : <br /> SITE MAP ATTACHED** :* 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 />