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PHS-EHD - UNDERGO <br /> ND TANK CLOSURE/ABANDONMENT INSPECTION <br /> (SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br /> 'E OWNER NAME _ OWNER PHONE # � <br /> a ;7/ <br /> E CONTRACTOR Q f <br /> V �`� J� uc�Zc CON. PHONE# <br /> fr3S - <br /> R SJLHD PERMIT # •' <br /> A EPA # FIRE PER # <br /> INSPECTOR QZ DATE <br /> R RINSED �N) METHOD <br /> I �`r re 3 RINSE AMU N SS <br /> N RINSATE DISPOSAL SITE ins <br /> S cfri/e cr <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED (Y N) METHOD <br /> R I e�- ice AMOUNT USED <br /> P L. E, L. READING AT REMOVAL (MUST BE ( 20%) <br /> 0 <br /> T R COMMENTS 9 <br /> A <br /> N TANK MATERIAL ( TEE , FIBERGLASS, OTHER) TANK SIZE 4Pt� <br /> K C /0 00(7 tiQ <br /> / O TANK CONDITION OD POOR, HOLES) <br /> N <br /> S PIPE MATERIA (S'fEE FIBERGLASS, OTHER) # FEEf <br /> P T <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION <br /> T SAMPLE # <br /> F <br /> I N silf c / t� r S <br /> E K <br /> L <br /> D EXCAVATION SIZE: <br /> S - X X YDS OF SOIL: <br /> I A DEPTH SOIL TYPE OBSERVATION <br /> N M P SAMPLE <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X <br /> I ,.-- X YDS OF SOIL <br /> 0 H DEPTH TO G. W. ; <br /> N ` FT SAMPLING METHOD /Z' / <br /> --- < �'7i hNr <br /> G # OF HOURS SINCE DEWATERING: <br /> O OTHER SAMPLE: <br /> LABORATORY: /Gra` C�PkFr��C s"' <br /> SAMPLERS NAME : -- <br /> CLOSURE IN PLACE MIXTURE: <br /> VOLUME <br /> EH 23043 ( 19/89) DRAW SITE MAP ON REVERSE <br />