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PHS-EHD - UNDERGRL`r1D TANK CLOSURE/ABANDONMEN, INSPECTION <br /> (SHADED AREA TO BE FILLED IN <br /> ur a ur Pm FONLY)"7 <br /> ua 7 <br /> uNaH <br /> o 4R <br /> 121�� ad <br /> OWNER NAME./I�� � OWNER PHONE # (Z0q)4tv(L 9g <br /> E CC' <br /> N CONTRACTOR ,. le CON. PHONE# C2d9 }� IZ <br /> E WW CRG cco <br /> R SJLHD PERMIT # EPA # 5 qrJ� FIRE PERMIT # � (-Ob� <br /> A <br /> L — <br /> INSPECTORUle. DATE 3 `J c31 TANK # 39 <br /> R RINSED Y N) METHOD'�CIOi t t2InSe- RINSE AMOUNT p� <br /> I <br /> N RINSATE DISPOSAL SITE -7t7cln.er-L, S�rvkcs <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED (Y N) METHOD �� RMOUNT USED � �S <br /> A <br /> P L. E. L. READING AT REMOVAL (MUST BE < c0%) R <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL TEEL, FIBERGLASS, OTHER) TANK SIZE D <br /> K C <br /> / 0 TANK CONDITION (GOOD POOR HOLES) �C t C Got(G�jiE"� eV'•d <br /> N <br /> S PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET I0 <br /> P T <br /> I PIPING CONDITION GOOD POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> F A - <br /> I N <br /> N <br /> E K <br /> L a <br /> D EXCAVATION SIZE: X X � YDS OF SOIL: �L V <br /> S <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> N M P <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X X YDS OF SOIL <br /> I <br /> 0 H DEPTH TO G. W. : u FT SAMPLING METHOD <br /> N 2 <br /> U # OF HOURS SINCE DEWATERING: — <br /> -I OTHER SAMPLE: <br /> LABORATORY: LPB SAMPLERS NAME:— <br /> CLOSURE IN PLACE MIXTURE: NIS VOLUME: n( or <br /> EH 23043 ( 10/89) DRAW SITE MAP ON REVERSE <br />