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+ SJLHV - UNDERGRUUND 'TANK CLOSURE/ABANDOVh8WT INSPECTION <br /> (SHADED AR' _ TOBE FILLED <br /> IN FOR OR THE F ST TANK ONLY) <br /> 4 y <br /> G OWNER 'NAME ! <br /> SIA OWNER PHONE # y�Sr 1 <br /> E 93 - <br /> N ; CONTRACTORI ? <br /> �� <br /> �,�. CON. PHONE# ���� <br /> E <br /> f R SJLHD PERMIT # EPA # FIRE PERMIT # -� <br /> A <br /> L <br /> INSPECTOR � r DATE/ Z/� �'� TANK # 39 - 171 <br /> _ 1 <br /> R RINSED (YIN) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE , <br /> S <br /> E MANIFEST # -OR- OTHER <br /> —7 <br /> V VAPORS PURGED-&( N) " METHOD eq, AMOUNT USEDIf- <br /> A <br /> P L.E.L. READING AT REMOVAL MUST BE < 20%) <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL. r STEE , FIBERGLASS, OTHER) TANK SIZE e0o - <br /> K C <br /> / 0 TANK CONDITION (GOOD)ti POOR,�HOLES ) <br /> P N c � <br /> I US PIPE MATERIAL {STE , FIBERGLASS, OTHER) # FEET <br /> P �_-...--IPIPING CONDITION - (GOOD, POO , .HOLES ) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> F A y, <br /> I N v <br /> E K j <br /> D EXCAVATION SIZE: _.1/__o X fZ X YDS OF SOIL..AG � <br /> S- <br /> I A DEPTH 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 /> O H DEPTH TO G.W. : FT SAMPLING METHOD <br /> . N 2 <br /> 0 # OF HOURS SINCE DEWATERING: <br /> ❑O OTHER SAMPLE: <br /> LABORATORY: �6G SAMPLERS NAME �,� r <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />