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3JLMO - UNDERGROUND TANK CLOSURE/AI)ANDONMEN'r INSPECTION <br /> (SHADED ARE PO BE FILLED IN FOR THE F. 'T TANK ONLY) <br /> G < OWNER NAME OWNER PHONE # �3 _-37Sz <br /> E <br /> N < CONTRACTOR2� CON. PHONE# �z N _y65j <br /> E <br /> R < SJLHD PERMIT # EPA # FIRE PERMIT # <br /> A <br /> L fm Wilifflpm— <br /> INSPECTOR � DATE/, /,y/J/ TANK # 39 <br /> R RINSED Y N) METHOD RINSE AMOUNT ."' <br /> I <br /> N RINSATE DISPOSAL SITE ;., <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED (Y)N) METHOD AMOUNT USED ` <br /> A <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20%) <br /> O <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL (STEE FIBERGLASS, OTHER) TANK SIZE <br /> K C _'- - <br /> / 0 TANK CONDITION (GOOD 00k' HOLES ) <br /> P N <br /> I S PIPE MATERIAL STEEL FIBERGLASS, OTHER) # FEET mac' <br /> P T - <br /> I PIPING CONDITION (GOODOBO-OR',, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> i <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 I °r c o tiZi u <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 mo <br /> DEPTH TO G.W. : FT SAMPLING METHOD <br /> N <br /> # OF HOURS SINCE DEWATERING: <br /> u❑O OTHER SAMPLE: <br /> l LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />