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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : SQ'NWay NO C4nte1r OCIGM SR# : 008292y <br /> ADDRESS : 1891 W • rrIeywn &I CITY: T �ac�i <br /> OWNER NAME : &7%kWo InC • PHONE : Q`15 - 4GI - 3QTI <br /> CONTRACTOR : Grg11lt4 PV/fMi, eATl1 . 1nG PHONE : 50�1 - �182 - 10i (o <br /> FIRE PERMIT # : TANK # 39 <br /> PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR : GGfU i P ( Q9gtV DATE : y .- 21 - 20 . 1 <br /> R RINSED : F1 YES El NO METHOD : AMOUNT : <br /> I <br /> N RINSATE DISPOSAL SITE : <br /> S <br /> E MANIFEST M 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 (gal) : <br /> O TANK CONDITION : F1 GOOD ❑ POOR ❑ HOLES COMMENTS*: <br /> N <br /> S PIPE MATERIAL : ❑ STEEL JFIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING (ft) : <br /> T PIPE CONDITION : GOOD ❑ POOR El HOLES COMMENTS* : <br /> DEPTH (ft) SOIL TYPE OBSERVATION* SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> 8 �6 <br /> EXCAVATION SIZE (length x width x depth) : ft X ft X ft <br /> SEE <br /> DEPTH (ft) SOIL TYPE OBSERVATION * SAMPLE # <br /> A P 2 .f+ max wil ciuj � IQan , nQ ddurs p¢ r AP T1 M 9am>�1ers oar - 1 I tuft) <br /> M I I-++ hMK Wtj Q10H QkOV) - nQ ad0l ; fir INK10 samPWV �sT - 31 1 C2 f4 ) <br /> P P tj ft Lack 411ti tyN clean , ri wag 1c hKIM gIrnO fs ho Cz ft <br /> L <br /> E 2 alac4c s l c1c �i zoh na adlU>5 ozr APT iM sv �1Alw s us t ( ij (2 tt <br /> -S N TRENCH SIZE (length x width x depth) : I ;cl ft X S ft X 2 ft <br /> G H DEPTH TO GROUNDWATER (ft) : # HOURS SINCE DEWATERING : <br /> 2 <br /> O SAMPLING METHOD : OBSERVATION*: <br /> STOCKPILE#1 : VWN Cubic Yards COVERED : ❑ YES ❑ NO SAMPLE # r1U1 SAMPLE # nUf1� <br /> STOCKPILE#2 : P0119 Cubic Yards COVERED : ❑ YES ❑ NO SAMPLE # SAMPLE # n (J)10 <br /> OTHER SAMPLES : <br /> LABORATORY: Wz (;(ilii'(� t♦ir1CAlICU� SAMPLER' S NAME : fad Del n0gro (.hPCI M ) <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED** : [� YES ❑ NO <br /> EH 23-0043 (Rev 03/04/15) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all commentslobservations ** Site Map Required <br />