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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UST/PIPING CLOSURE INSPECTION FORM <br />SITE NAME: CITC1 e<L SR#: <br />ADDRESS: 5 � 2 L g, CITY: <br />OWNER NAME: (sod 4 ",1., PHONE: <br />CONTRACTOR: PHONE: <br />I-lKt PERMIT P: TANK # 39 Az cl <br />U PIPING REMOVAL --BUST REMOVAL U CLOSURE IN PLACE U TEMPORARY CLOSURE <br />INSPECTOR: DATE: Dec -x , 14 <br />R <br />1 <br />RINSED- %1YES L3 No <br />METHOD:NT: <br />N <br />RINSATE DISPOSAL SITE: <br />S <br />E <br />MANIFEST #: <br />OTHER TRACKING #: <br />V <br />A <br />P <br />0 <br />R <br />PURGEP%WES L3 NO <br />READINGS AT REMOVAL: <br />METHOD: AMOUNT USED: <br />L.E.L.: 02: COMMENTS*: <br />a�; <br />C <br />TANK MATERIAL -,a STEEL L3 FIBERGLASS L3 OTHER <br />TANK SIZE <br />0 <br />N <br />TANK CONDITION: L] GOOD h&° POOR L3 HOLES Comments*: Cid JrX <br />S <br />PIPE MATERIAL;,U) STEEL L3 FIBERGLASS L3 OTHER —TTOTAL <br />LENGTH OF PIPING <br />T <br />PIPE CONDITION: Ak GOOD L3 POOR L3 HOLES Comments*: <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* SAMPLE# <br />T <br />rr <br />JO r" qJ <br />A <br />,he1 e i A, 7 fi- <br />N <br />EXCAVATION SIZE: X X <br />Length Width Depth <br />S <br />DEPTH <br />SOIL TYPE <br />OBSERVATION* <br />SAMPLE# <br />A <br />P <br />M <br />I <br />P <br />P <br />L <br />E <br />I <br />N <br />TRENCH SIZE: X X <br />Length Width Depth <br />G <br />HDEPTH <br />2 <br />] <br />TO GROUNDWATER: FT <br /># HOURS SINCE DEWATERING: <br />0 <br />SAMPLING METHOD: <br />OBSERVATION*: <br />STOCKPILE#1: Cubic Yards COVERED: Q YES , rNO SAMPLE# S P SAMPLE# <br />STOCKPILE#2: Cubic Yards COVERED: ')IO*YES Q NO SAMPLE # 5 SAMPLE # <br />OTHER SAMPLES: <br />LABORATORY: -7!Z-Grcv <br />SAMPLERS NAME: jj <br />Ubfi- <br />CLOSURE IN PLACE: I <br />BACKFILL MIXTURE: <br />VOLUME: <br />SITE MAP ATTACHED": );ihYES L3 NO <br />EH 23-0043 (Rev 5/22/2007) IMPORTANT NOTES: Complete one form for each tank removed <br />* Include all commentsiobservations ** Site Map Required <br />