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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME : SI1QI1 Krill MQCt SR# : �u5525 <br /> ADDRESS : 2324 N . E ! V0010 St . CITY : S'fiMY) <br /> OWNER NAME : BOO 9L KGIR'hy Wi PHONE : 249 - ay3 - 131 i <br /> CONTRACTOR : WM IV COT OCtOYS PHONE : 209 - q (oI o34 <br /> FIRE PERMIT # : TANK # 39 <br /> PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR . (UT (JI PrpsCCi DATE : � 0 � I � 120ZZ <br /> R RINSED : AYES ❑ NO METHOD : trlp1Qi r MnSQdAMOUNT : 110 AW <br /> I <br /> N RINSATE DISPOSAL SITE : IQO all !;n9j ►1') Vim UJQM dnlrns C fiWQ 55 - gqi <br /> S <br /> E I MANIFEST # : 7 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 /> 7 <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 ^` 15 -M <br /> T PIPE CONDITION : ❑ GOOD ❑ POOR ❑ HOLES Comments* : 0j (1q gW <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE : X X <br /> Length Wldth Depth <br /> S DEPTH SOIL TYPE OBSERVATION * SAMPLE # <br /> AP 004 owwn , no adu , ra s;wt nin PPI <br /> M I (� CI praW�l , no udGY , nG gloriarg Pp2 <br /> P P (9 '' CIS b MhA , 11G cd ar , M MInn PP5 <br /> E (01 <br /> ' CIN branrn , nv oft , no s-rainrl <br /> TRENCH SIZE : qq, X 2 , X 3 ' <br /> N Length 4Ndth Depth <br /> G H DEPTH TO GROUNDWATER: FT # HOURS SINCE DEWATERING : <br /> 2 <br /> p SAMPLING METHOD : OBSERVATION* : <br /> STOCKPILE# 1 : 50 Cubic Yards COVERED : ❑ YES 4, NO SAMPLE # SS1 SAMPLE # S52 <br /> STOCKPILE#2 : Cubic Yards COVERED : LI YES NO SAMPLE # SAMPLE # <br /> OTHER SAMPLES : <br /> LABORATORY : EV1'VWj 1- CM (Y) SAMPLERSNAME % MC# WQII NfkMjPr <br /> CLOSURE IN PLACE : BACKFILL MIXTURE : VOLUME : <br /> SITE MAP ATTACHED** : AYES ❑ NO <br /> EH 23-0043 (Rev 512212007) IMPORTANT NOTES : Complete one form for each tank removed <br /> * Include all comments/observations ** Site Map Required <br />