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SJLHD — UNDFRGROUND 'TANK CLOSURE/A4ANDONMENT INSL'LC'1'lUN <br /> (SHADED A I R# TO BE FILLED IN FOR THE ANST TANK ONLY) <br /> G OWNER NAME <br /> E GtJCS✓ti�n /7zC1�� OWNER PHONE <br /> ECONTRACTOR CON. PHONE# <br /> R < SJLHD PERMIT I EPA I FIRE PERMIT 0 <br /> A . . /.fid � P <br /> Lam : <br /> INSPECTOR !J /�� DATE c -2_ y TANK 1 39 <br /> R RINSED (Y, l METHOD RINSE AMOUNT <br /> • I <br /> N RINSATE DISPOSAL SITE <br /> J -\ <br /> E MANIFEST Y -OR- OTHER <br /> VA VAPORS PURGED r/N) METHODy , t _ AMOUNT USED �" <br /> r �o <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20%) <br /> 0 <br /> T R COMMENTS <br /> A -_�- <br /> N TANK MATERIAL VSTEE -. rIBERGLASS, OTHER) TANK SIZE <br /> K C <br /> / N TANK CONDITION /(GOOD;) POOR, HOLE)) i5uo , _ {yam E <br /> „I S PIPE MATERIAL (STEEL, FIBERGLASS,' OTHER) V FEET / <br /> P T <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE Y <br /> T <br /> F A c <br /> I N <br /> E K <br /> L <br /> D EXCAVATION SIZE: JL X --L X YDS OF SOIL: <br /> S; <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE Y <br /> N M P <br /> S P I <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 H DEPTH TO G.W. : FT SAMPLING METHOD <br /> N 2 <br /> 0 1 OF HOURS SINCE DEWATERING: <br /> O1OTHER SAMPLE: <br /> LABORATORY: (t cttiGr � SAMPLERS NAME. <br /> A c <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />