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PHS-EHD - UNDERG IA TANK CLpSURE/AnANDpNM4INSPECTION r--- <br /> (SHADED AREA TO DE' FILLEDS <br /> IN FOR THE FIRSTTANK ONLY) <br /> OWNER NAME ._- OWNER PHONE #) r, <br /> i <br /> N CONTRACTOR CEN, F'HDNE#) 0 <br /> K5 <br /> SJLHD PERMIT # E ( ,C°° 57?c/2S, FIRE PERMIT <br /> L <br /> INSPECTOR _ <br /> �,� � .�.,..✓7:/ DAT � .TANK <br /> R RINSED {{Y/ THOD ��/1��� �? <br /> I / �/ �r�S R I NSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> MANIFEST #i -OR- OTHER <br /> vVAPORS PURGED METHOD AMOUNT USED <br /> P L.E. L. READING AT REMoV6L (MUST RE ( ;GiC) 1c6�r6�-e� <br /> L P-(-. <br /> T <br /> - <br /> T R COMMENTS <br /> N TANK MATERIAL ( TCEL,) FID;ERGLA.�'.',S, OTHER) TANK SIZE". qAj <br /> K C --�. <br /> / til TANK CONDITION (GOOD,(f'bOR,rHOLEN <br /> +" S PIPE MATERIAL STEE ,; FIBERGLASS, OTHER) 44 FEET <br /> P T J <br /> I PIPING CONDITION �G06r) POOR, HOLES) <br /> N _ <br /> G DEPTH SOIL TYPE ' QBSERVATION SAMPLE. # <br /> tj <br /> IN I /� 1n 4.i_ 0\91 t' �r� <br /> E K. a <br /> L � <br /> D EXCAVATION .SIZE: "� 1 X X YDS., OF SOIL: <br /> S <br /> I A DEPTH SOIL, TYPE OI�SEF"VATION SAMPLE # <br /> N M F ! n ! L_ -I <br /> I/ Ili " Ab <br /> LL <br /> T G TRENCH DIMENSION X 3 x YDS GF- SO I L <br /> I _ <br /> D H DEPTH TO G. W. <br /> 0 # OF HOURS SINCE DEWATERING: <br /> 1 O OTH <br /> _R SAMPLE <br /> LABORATORY: - 't j SAmPLERS NA1nE :` • ,� �- <br /> CLOSURE IN PLACE MIXTURE: VOLUI~Il=: � <br /> FH 2`2043 ( 10/89) DRnW SITE MAP ON REVERS: <br />