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PHS-EHD - UNDERGROUND TANK CLOSURE/ABANDONMENT ZIzISPECTION <br /> (SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br /> El K hor�wu.�.uvtlru�,��..� - V-A'l 05U AJ K7 �.. Cr`Y'r"'( � <br /> 0 NER NAME 600 yOUnj OWNER PHONE #(2C)q) 14'-. �-88�� <br /> N CONTRACTORWeS+e'Yn rn2LY6e� CON. PHONE#(2oCl) gLjg-& lzq <br /> E J <br /> R SJLHD PERMIT # 03i ) A EPA #ojgCo p E PERMIT # �35� <br /> A � � <br /> L <br /> INSPECTOR ��� DATE L5-1;-71 ( l TANK # <br /> R RINSED NN) I METHOD rjpt , K�n5,p RINSE AMOUNT '�� <br /> I <br /> S RINSATE DISPOSAL SITE e �✓ I C-P-ID .J'YI c� i <br /> E MANIFEST # -OR- OTHER I <br /> V VAPORS PURGED (Y N) METHOD^ J C� AMOUNT USED J J I h S16 <br /> A <br /> P L. E. L. READING AT REMOVAL (MUST BE C 20%) D L4'1Z'7b <br /> 0 / <br /> T R COMMENTS Q (e6� /7?r lC� dbxyl <br /> R <br /> N TANK MATERIA (STEEL; FIBERGLASS, OTHER) TANK SIZE <br /> K C <br /> / O TANK CONDITION (GOOD, POO , HOLES) COYYa57 <br /> N <br /> S PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET N �p <br /> P T <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # ` <br /> F l T <br /> I Ns <br /> E KD t/-Z Sd4tA4ca mw dory cev� no - S q� T� <br /> I <br /> L 0 <br /> D EXCAVATION SIZE: �� X ID X � YDS OF SOIL: Z <br /> S <br /> I ADEPTH SOIL TYPE OBSERVATION SAMPLE # <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 /> I IL <br /> N 2 <br /> 0 # OF HOURS SINCE DEWATERING: <br /> ❑O OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: Pa� / C � <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> 22043 ( 10/89) DRAW SITE MAP ON REVERSE <br />