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S <br /> JLHD — UNDERGROUND 'TANK CLOSURE/AUNDONMEN'1' I NSNEC'rI UN <br /> SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br /> G OWNER NAME OWNER PHONE p �' <br /> N CONTRACTOR CON, PHONE# • <br /> E <br /> R SJLHD:-PERMIT 1 EPA t <br /> A FIRE PERMIT 1 <br /> INSPECTOR Cr CJ DATE TANK 1 39 <br /> R RINSED ( 7'N) METHOD <br /> RINSE AMOUNT <br /> LCC�� e� <br /> N RINSATE DISPOSAL SITE <br /> E MANIFRST <br /> ._. —OR— OTHER <br /> V VAPORS PURGED Y/'N) AMOUNT USED <br /> METHOD <br /> . P L.E.L. READING AT REMOVAL (MUST BE < 20%) <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL ( TEEL; FIBERGLASS, OTHER) TANK SIZI <br /> K C <br /> / O TANK CONDITION (GOOD,(-PQp)HOLES) <br /> P N <br /> I S PIPE MATERIAL (3TEEL, SS, OTHER) <br /> FEET, FIBERGLA <br /> yP - T � <br /> I PIPING CONDITION (GOOD, <br /> N 00 Sa HOLE <br /> G DEPTH SOIL TYPE OBSERVATION <br /> T SAMPLE 1 <br /> F A <br /> IN 41 <br /> E K <br /> L <br /> D EXCAVATION SIZE: X <br /> S' X ` YDS OF SOIL: , o yc f <br /> I A DEPTH SOIL TYPE OBSERVATION <br /> N M P SAMPLE µ <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> z G TRRNCH DIMENSION X X <br /> YDS OF SOIL <br /> O H DEPTH TO G.W. : <br /> N 2 --�,.. FT SAMPLING METHOD <br /> 0 1 OF HOURS SINCE DEWATERING: <br /> 50_� <br /> OTHER SAMPLE: <br /> L--LABORATORY: C?4'�r�v/, c .6ci' 3 «z.�. <br /> �,/ .. SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE:• <br /> VOLUME: <br />