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PHS-EHD UNDOROUND TANK CLOSURE/ABAND <br /> (SHADED AREA TO BE FILLED IN ENT INSPECTION <br /> • a ����JIf-Tf��� FOR THE FIRST TANK ONLY) <br /> OWNER' NAME <br /> OWNER PHONE # ��Q <br /> N CONTRACTOR �G i �/ 7 k . <br /> C CPN. PHONE#t 7 a� T <br /> R SJLHD PERMIT # 6 53 <br /> A . 1 � EGA # FIRE PERMIT # � <br /> L <br /> f <br /> INSPECT0R4�. t - <br /> S� DATE TANK # u9 - <br /> R RINSED (Y/N) METHOD V <br /> I RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S ti <br /> E MANIFEST # <br /> -'SR- OTHER <br /> V VAPORS PURGED (Y/N) � <br /> A MC OD AMOUNT USED <br /> P L.E. L. READING AT REMOV (MUST BE ( �,;�) <br /> O <br /> T R COMMENTS <br /> N TANK MATERIAL <br /> K C CL, FIBERGLASS, OTHER) TANK SIZE <br /> / 0 TANK CONDITIO (GO <br /> N OD, F'OOR, HALES) <br /> S PIPE MATER AL (STEEL, FIBERGLASS, OTHER) # FEET <br /> P T <br /> I WIPING CONDITION (GOOD, <br /> N POOR, HOLES) <br /> G DEPTH SOIL TYPE c� _ - <br /> T OBSERVATION <br /> F SAMPLE # <br /> A <br /> I N r <br /> E K <br /> L <br /> D <br /> EXCAVATION SIZE: / � r <br /> S '"� X <br /> I A DEPTH SOYDS OF SOIL: <br /> IL TYPE <br /> N M P OBSERVATION <br /> P I SAMPLE # <br /> S <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION <br /> I "- X `-- X YDS OF SOIL <br /> O 1 H DEPTH TO G. <br /> N W. --~------• FT SAMPLING METHOD <br /> 0 # OF HOURS SINCE DEWATERING: <br /> O OTHER SAMPLE: <br /> LAB0RATORY: C-4L to,4'-5R / _ bS SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: <br /> VOLUME: <br /> EH 23043 ( 1D/fig) DRAW SITE MAP ON REVERSE <br />