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UNDrMROUND TANK C;L OSLlRE/AT AND NT INSPECTION <br /> (SHADED} ATE O BE FILLER IN FOR THE F <br /> TANK ONLY) <br /> CIi.JNTIRNAME C3WNT�R PH©NTS } <br /> E <br /> N CONTRACTOR <br /> E CON. PHONE# <br /> R SJLHO S3-1Oi ERMi <br /> A PA # FIRE Et*i T <br /> L <br /> INSPECTOR ITE TANK - <br /> R RINSEDO( /N) METHOD <br /> RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S : , <br /> E MANIFEST # —CTR—, EITHER <br /> V VAPORS PURGE I'� N) METHOD AMC)LJNfi USED <br /> A r <br /> L. L. READING AT REMOVAL (MUST BE 20%) ,. <br /> CI <br /> T R COMMENTS <br /> TS <br /> A <br /> TANK MATERIAL EE FIBERGLASS, OTHER) TANK SIZE y <br /> K C 00 <br /> C TANK CONDITION C 1 , POOR, HOLES) <br /> N <br /> T 'IPTG MATERIAL STEE FIBERGLASS, OTHER) # FEET <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N , <br /> S DEPTH 'SOIL TYPE OBSERVATION SAMPLE � <br /> T <br /> F A ,. <br /> I N <br /> E <br /> L <br /> D EXCAVATION SIZE: XYi3S OF SOIL: <br /> S <br /> I A DEPTH SOL TYPE OBSERVATION SAMPLE # <br /> RNs M P <br /> S ti I <br /> P L P <br /> C: N <br /> T G TRENCH DIMENSION X X YDS CIS SOIL <br /> I <br /> D H DEPTH TO G. W FT SAMPL I NC METHOD <br /> N <br /> # OF HOURS SINCE DEWATERING.- <br /> 0 OTHER SAMPLE: <br /> LAB€3RATORY a i✓ cr> SAMPLERSNAME: <br /> CLOSURE IN PLACE mix <br /> VOLUME: <br /> EH 23043 10/89} DRAW SITE MAP ON REVERSE <br />