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iJ <br /> UNDERGZC"ND TANK CLOSURE/ABANDONME14— � <br /> (SHADED AREA TOFILLED IN FOR THE FIRSTI 4K ONLLY O <br /> ��UK Y)) <br /> ' a t,�'sYirirv�qui�i/�rfuruyrrrr.�wrdiarrrurra/G.wrurrrurcvurvi/rrruwr rvru,�/c'/r1 .ryeri�'uirra�.Grtvirrurrrrururirrrrrr srrr�!!/!lJJII!//YJl'fUIU <br /> I� QwNER NAME OWNER PHONE # <br /> I E I <br /> N CONTRACTOR <br /> CON. . PHCNE# <br /> R . SJLHD PERMIT # EPA # , <br /> i A M-1 -119"ll FIRE PERMIT #G —5/1" lTd!L t'!UV L ubi.IK- 1tV <br /> INSPECTOR t {L <br /> RATE j�/ZVCl, TANK # a9 <br /> i <br /> i <br /> R RINSED ( /N) METHOD RINSE AMOUNT <br /> I 1 I <br /> s N RINSATE DISPOSAL SITE <br /> S , <br /> I E MANIFEST # —OR— OTHER ' ; <br /> V I VAPORS PURGEr? &N) METHOD AMOUNT USED <br /> j I P I <br /> L. E. L. READING AT REMOVAL (MUST AE C wd <br /> 0 <br /> — <br /> j R COMMENTS <br /> A i , <br /> N ! TANK MATERIAL =, FIBERGLASS, 'OTHER) i TANK SIZE <br /> f <br /> K <br /> / f 0 TANK CONDITION (GOOD, 00 HOLES) j <br /> I S PIKE MATERIALT�— L�,.iFIBERGLASS, OTHER) # FEET I , <br /> P 1 I <br /> I i PIPING CONDITION (GOODOLES) <br /> N ; <br /> j Gi DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T � <br /> 1 R I A I <br /> I N I I <br /> K <br /> f L l I 1 <br />! D I ! EXCAVATION SIZE: V7 1X �X r YDS OF SOIL: <br />+ S 11 <br /> j I A DEPTH SOIL TYPE ' OBSERVATION SAMPLE # <br /> N M P <br /> S P I i <br /> I P L P <br /> E I E ! <br /> C N <br /> T G ! TRENCH DIMENSION X X YDS OF SOIL <br /> I ' <br /> 0 i H ( DEPTH TO G. W. : FT . SAMPLING METHOD . <br /> N i 2 <br /> 0 # OF HOURS SINCE DEWATERING: <br /> I . <br /> r; <br /> I i 0 � OTHER SAMPLE: <br /> f "I LABORATORY. SAMPLERS NAME: <br /> i <br /> j <br /> CLOSURE IN PLACE MIXTURE: ! VOLUME: t <br /> 2�c� ( I0/8S) DRAW SITE MAP ON REVERSE - ------- <br />