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PHS-EHD - UNDERGRJ TANK CLOSURE/ABANDONME y ,NSPECTION <br /> (SHADED AREA TO'!�E FILLED IN FOR THE FIRST WNK ONLY) <br /> NMI <br /> E OWNER NAME +1J OWNER PHONE # � 4+1 - <br /> N CONTRACTOR CON. PHONE# ` fJ L4 -�-{ <br /> E <br /> R SJLHD PERMIT # EPA #CSG�� F IRE PERM I T # j ZCj <br /> A <br /> -:�-jJill,mi'l 1,L HL CUSURE 11101 1 <br /> I'll .11 iff <br /> INSPECTOR DATE i2/2, t$c� TANK # 39 - (634-4 - �- <br /> R RINSED Y N) METHOD-Fri oe -��n RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED (Y N) METHOD D}Zy Ci✓ AMOUNT USED i <br /> A <br /> P L. E. L. READING AT REMOVAL (MUST BE < <br /> 0 <br /> T R COMMENTS <br /> - <br /> A ^ <br /> N TANK MATERIAL (CT <br /> EL <br /> K C FIBERGLASS, OTHER) TANK SIZE lS��.y GZ. <br /> / O TANK CONDITION (GOOD, HOLES) C-CrRRCSiON <br /> N <br /> S PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET ' jD <br /> P T <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> F A �- C. a <br /> I N _ - <br /> E K i '71 ,Nl 4T <br /> L <br /> D EXCAVATION SIZE: 1 X iZ X YDS OF SOIL: � <br /> S � <br /> I A DEPTH OIL TYPE SERVATION AMPLE # <br /> N M P <br /> S F' I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X X YDS OF SOIL <br /> I <br /> O H DEPTH TO G. W. :P&21��� FT SAMPLING METHOD - <br /> N 2 <br /> G # OF HOURS SINCE DEWATERING:-4e- <br /> 0- OTHER SAMPLE: <br /> LABORATORY: jL(� (���t- EN o. <br /> - 7 SAMPLERS NAME:$ALA--N �,�y N a <br /> CLOSURE IN PLACE MIXTURE: VOLUME: (j <br /> EH 23043 ( 10/89) DRAW SITE MAP ON REVERSE <br />