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PHS-EHD - UNDERIOUND TANK CLOSURE/ABANDONMRT INSPECTION <br />(SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br />� iXl/rXOiY!/rY!/N4�'LGY//N/G 'w/m/n/m/aim/m/w vow — <br />OWNER NAME " <br />E / OWNER PHONE # <br />N CONTRACTOR CON. FHONE# <br />E X05 - �'3 "7- NO <br />RSJLHD PERMIT # EPA # <br />A FIRE PERMIT # <br />L <br />p <br />INSPECTOR L& 5 L h DATE TANK <br />R RINSED (Y/N) METHOD <br />I RINSE AMU N"f <br />N RINSATE DISPOSAL SITE <br />S <br />E MANIFEST # <br />-OR- OTHER <br />V VAPORS PURGED (Y/N) METHOD <br />A AMOUNT USED <br />F' L.E.L. READING AT REMOVAL (MUST BE ( 2C)%) <br />0 <br />T R COMMENTS <br />A <br />N TANK MATERIAL (STEEL, FIBERGLASS, OTHER) TANK SIZE <br />K C <br />/ 0 TANK CONDITION (GOOD, POOR, HOLES) <br />N <br />S PIPE MATERIAL (STEEL, FIBERGLASS, <br />P T OTHER) # FEE"f <br />I PIPING CONDITION (GOOD, POOR, HOLES) <br />N <br />G T DEPTH SOIL TYPE OBSERVATION,' <br />S <br />F A l� <br />I N <br />E K D J <br />L et7n,rn� _ <br />D V <br />EXCAVATION SIZE: l`� <br />S .TX L X �� YDS OF SOIL: <br />I A DEPTH SOIL TYPE OBSERVATION <br />NM P <br />S P I <br />F' L P <br />E I E <br />C N <br />T G TRENCH DIMENSION <br />I X — X YDS OF= SOIL <br />0 H DEPTH TO G. W. : <br />N 2 FT SAMPLING METHOD <br />G # OF HOURS SINCE DEWATERING: <br />0 OTHER SAMPLE: <br />LABORATORY: a ���_� ��ct E SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VI:]LUhIE <br />EH 23043 (10/B9) DRAW SITE MAP ON REVERSE <br />SAMPLE # <br />SAMPLE # <br />