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SJLHD — UNDERGDOUND TANK CLOSURE/ABANDONMENT INSPECTION <br /> (SHADED AREA ) BE FILLED IN FOR THE FIR ' TANK ONLY) <br /> :1 j1�1:jlC1:jt1:jlt1:jl,goj! <br /> pi i <br /> L,J I <br /> G7OWNERME�/l OWNER PHONE # <br /> E <br /> NORSala CON. PHONE#E <br /> RRMIT # EPA # FIRE PERMIT # <br /> A <br /> L 7 <br /> INSPECTOR ,--K DATE�{'.�_Q TANK # 39 — <br /> R RINSED (Y N) METHOD RINS ILMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # A214 —OR— OTHER <br /> V VAPORS PURGED Y N) METHOD A=, USED <br /> USED <br /> A JAnil <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20%) N44 <br /> 0 <br /> T R COMMENTS <br /> N TANK MATERIAL STEE , FIBERGLASS, OTHER) TANK SIZE • DQ i . <br /> K C <br /> / 0 TANK CONDITION ; GOOD POOR, HOLES) <br /> P N <br /> I S PIPE MATERIAL STEE , FIBERGLASS, OTHER) # FEET <br /> P T <br /> I PIPING CONDITION {GOOD POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T S <br /> F A <br /> I N <br /> E K <br /> L <br /> D EXCAVATION SIZE: X X YDS OF SOIL: <br /> S= <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> N M P <br /> S P <br /> P L P <br /> E I <br /> C N <br /> T G TRENCH DIMENSION X _ X YDS OF SOIL <br /> I <br /> 0 H DEPTH TO W. : FT SAMPLING METHOD <br /> N <br /> 0 # OF H RS SINCE DEWATERING: <br /> O OTHE SAMP E: <br /> LABORATORY: SAMPLERS NAME• <br /> CLOSURE IN PLACE MIXTURE:62 1 VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />