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PHS-EHD - UNDERGOND TANK CLOSURE/ABANDONM� INSPECTION <br />(SHADED AREA T E FILLED IN FOR THE FIRS ANK ONLY) <br />f�1,XYl,�I,�Y„�I,�%�'r�l�Y.�yr�r�?6/Yr�ti����'Gr���C�N��'�Y�,yP/�FrY'�iiX�d�i��uil��✓/rJy✓•xa�GrU��a�a�Hu�u,Y��:aurarurur�,�,rarura,�ura�a,�:,ruwcr�iw�w�w,wW� <br />EH 2,043 <br />10/69) DRAW SITE MAP ON REVERSE <br />7 <br />�• OWNER NAME OWNER PHONE # <br />I E %/�r� <br />N /CONTRACTOR CON. PHONE# <br />E "G J .✓YCo 20Q -Sacs - X653 <br />R SJLHD PERMIT # EFA #�A""" FIRE PERMIT # G!• N <br />zf s/v N p� <br />A.'l, <br />L <br />INSPECTOR �- of <br />DATE TANK # 3C) <br />R <br />I <br />RINSED Y/ > METHOD ` <br />/Tscc e GGA"� <br />RINSE f1MUUNT� <br />N <br />RINSATE DISPOSAL SITE <br />/615 <br />E <br />MANIFEST # -OR- OTHER <br />VAPORS PURGED (Y N) <br />METHOD,),,,,, _r <br />AMOUNT USED <br />AV <br />P <br />0 <br />L.E.L. READING AT REMOVAL (MUST BE ( COX) <br />T <br />R <br />COMMENTS <br />A <br />N <br />K <br />C <br />TANK MATERIAL (STEEL )FIBERGLASS, OTHER) TANK SIZE <br />_ y 400 <br />/ <br />O <br />R <br />TANK CONDITIO (,GOPOOR, HOLES) <br />N <br />r <br />S <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br />P <br />T <br />I <br />PIPING CONDITION (GOOD, POOR, HOLES) --- <br />N <br />G <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />T <br />F <br />A <br />�c 'C vi J- <br />/r / c• f�I- <br />E <br />�.. <br />K <br />L <br />0 <br />EXCAVATION SIZE: ✓�- X X YDS OF SOIL: <br />S <br />I <br />A <br />DEPTH SOIL TYPE <br />OBSERVATION <br />N <br />M <br />p <br />SAMPLE # <br />- <br />F' <br />L <br />P <br />E <br />I <br />E <br />C <br />N <br />T <br />I <br />G <br />TRENCH DIMENSION X X YDS Uf= SDIL <br />0 <br />N <br />H <br />DEPTH TO 0. W. FT SAMPLING METHOD <br />0 <br /># OF HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: G 1,;%' SAMPLERS NAME: <br />e0 ciNcT.�- ',- ZC'!h <br />, c <br />CLOSURE IN PLACE MIXTURE: <br />VOLUhIE: <br />J Z / <br />EH 2,043 <br />10/69) DRAW SITE MAP ON REVERSE <br />