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(SHADED 0 TO BE FILLED IN FOR THE*,,, RST+ TANK ONLY) <br /> ' ! K/ cz - <br /> G OWNER NAME �. OWNER PHONE # <br /> _ E : <br /> - , N i t CONTRACTOR <br /> CON. PHONE# : <br /> ..i_. ` E ; <br /> R SJLHD PERMIT EPA # W A FIRE PERMIT # <br /> 1A :. 1 NIA <br /> I • L <br /> INSPECTOR l DATE �� TANK # 39 <br /> f <br /> R RINSED (ON - METHODN RIt�J AMOUNT <br /> -- t N RINS.ATE DISPOSAL SITE /L <br /> YE � MANIFEST # —OR— OTHER <br /> E V VAPORS PURGED C(y METHODS AMOUNT USED <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20%) A)IA <br /> I 1 •• F �� 0 <br /> { i T R. COMMENTS <br /> t A t, <br /> N TANK MATERIAL (STEEL, FIBERGLASS, OTHEfc) TANK SIZE oO XlJlG <br /> t K . C: <br /> /. 0. TANK CONDITION (GOOD;(P00 , HOLES) <br /> P N! <br /> I S PIPE MATERIA (STEEL, 'FI-BE GLASS, OTHER) # FEET ��S�dGvttiCi <br /> _P_ _T <br /> I I ! PIPING CONDITION- (GOOD, POOR HOLES) <br /> t. . G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> _ 0 O1/ 0✓ !� 0 w � <br /> A <br /> - L i. . <br /> D EXCAVATION -SIZE: X X YDS OF SOIL: <br /> -�- I; zA DEPTH SOIL TYPE, OBSERVATION SAMPLE # <br /> -N tM - P , <br /> ^ <br /> S. ;P X <br /> Pt sL P <br /> .�. <br /> _ E I_ E <br /> T. G._ iTRENCH DIMENSION X X YDS OF SOIL <br /> 0, H ;DEPTH TO G.W. : FT SAMPLING METHOD <br /> N . 2 _ <br /> 14 OF HOURS SINCE DEWATERING: <br /> s 1 a -.OTHER SAMPLE: ­ <br /> . <br /> F LABORATORY:._. - SAMPLERS NAME: <br /> r_ - <br /> J. _CLOSURE- IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br /> v <br />