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"Lhu UNDERGRUUND TANK CLOSURE/AAANDONMENT INSPECTION <br /> (SHADED k ATO BE FILLED IN FOR THE rRST TANK ONLY) <br /> 111 HIM, <br /> in lecfil C l {r mdw <br /> E < OWNER NAME Q 1L CL _ M OWNER PHONE k <br /> CONTRACTORQ bC <br /> E Cfn6GT7ar(20 CON. PHONEN • 0p (4(ba1/0 <br /> q�z ?Al- <br /> R <br /> < <br /> i S:1J��LHD PERMIT Y E A L '� FIRE PERMIT k 1 <br /> L < <br /> INSPECTOR (. .�06,-5,itt DATE 1-6O `!cl TANK Y 39 - ( 1 <br /> R RINSED (Y)IN) METHOD RINSE AMOUNT C� (;, <br /> I .{YI 1� a. <br /> N RINSATE DISPOSAL SITE QK O-h Ftc(,fn'c UKIlj <br /> S <br /> E MANIFEST I -OR- OTHER <br /> V VAPORS PURGED (Y/N) METHOD 1)r Ce AMOUNT USED <br /> A �, <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20$) <br /> 0 <br /> T R COMMENTS <br /> A <br /> N ETANK <br /> MATERIAL (STEEL, FIBERGLASS, OTHER) TANK SIZE S <br /> K C ��� un <br /> / 0 CONDITION (GOO POOR, HOLES) <br /> P N <br /> II T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET d fX <br /> I PIPING CONDITION (GOOD, POOR, HOLES) rgVtx bb5t(V4CE <br /> N <br /> G T DEPTH SOIL TYPE OBSERVATION SAMPLE Y <br /> F A n <br /> I N IV <br /> E K <br /> L <br /> D3- 11 EXCAVATION SIZE: � X L X �n YDS OF SOIL : ' I <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE I <br /> N M I P <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION XX YDS OF SOIL <br /> I — <br /> 0 HEEH TO G.W. : FT SAMPLING METHOD <br /> N 2 <br /> 0HOURS SINCE DEWATERING: <br /> aOTHER SAMPLE: <br /> LABORATORY: Cct-rt G l ` SAMPLERS NAME: .�O� <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />