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PHS-EHD - UNDERGROUP TANK CLOSURE/ABANDONMENT �SPECTION <br />(SHADED AREA TO Bb -TILLED IN FOR THE FIRST TANK ONLY) <br />iE • % OWNER NAME <br />E T OWNER PHONE # <br />N CONTRACTOR <br />E CON. PHONE# <br />R SJLHD PERMIT # EPA # <br />A.r r r / FIRE PERMIT # <br />J <br />INSPECTOR /, DATE <br />< TANK # 39 <br />R RINSED (y N) METHOD <br />I was RINSE FIMOUNT, 30� <br />--SN1e <br />T <br />A <br />N <br />K <br />/ <br />P <br />I <br />N <br />G <br />F <br />I <br />J <br />i <br />N RINSATE DISPOSAL SITE n ' <br />S <br />E MANIFEST #/7�0�/� -OR- OTHER <br />V VAPORS PURGED111,111)/N) METHOD <br />Ap , S r AMOUNT USED <br />P L.E.L. READING AT REMOVAL (MUST BE ( 20%) <br />0 <br />R COMMENTS <br />TANK MA•fERIAL (STEE , FIBERGLASS, OTHER) TANK SIZE <br />C 3 So Rac be <br />0 TANK CONDITION (GOOD, POOR, HOLES) r <br />N �- <br />S PIPE MATERIAL (STEEL, FIBERGLASS, <br />T OTHER) # FEET.— <br />PIPING CONDITION (GOOD, POOR, HOLES) <br />DEPTH SOIL TYPE OBSERVATION R <br />SAMPLE # <br />A <br />N ., <br />K I <br />EXCAVATION SIZE: iO,X I X YDS OF SOIL: <br />S <br />A DEPTH SOIL TYPE OBSERVATION <br />M P SAMPLE # <br />P I <br />L P <br />I E <br />N <br />G TRENCH DIMENSION <br />— X .--. X YDS UF= SOIL <br />H DEPTH TO G. W,; <br />I FT SAMPLING METHOD <br />U # OF HOURS SINCE DEWATERING: <br />0 OTHER SAMPLE: <br />LABORATORY: <br />/vP7P%ti Eu /ra ,rrti,� SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: tA. <br />_ VOLUME: <br />23043 (10/89) DRAW SITE MAP ON REVERSE <br />!0a /' a..,/, r- <br />/rt.,;lpe/� <br />