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� 5 <br /> ; PHS-EHD UIVpERGE?"'�ND TANK CLOSURE/ABANDONME„�.� �j INSPECTION f <br /> .f (SHADED AREA T{a�, :- FILLED IN FOR THE F IRST`�raNK ONLY} ” <br /> OWNER NAME <br /> . � , C�ll�L� OWNER PHONE 7�d <br /> E <br /> ,y CONTRACTOR / <br /> �� N� niST,. CON. PHONE# <br /> R SJL;HD PERMIT -7/ <br /> A ' i i '� o 0/ FIRE PERMIT <br /> J <br /> xNSt✓ cr❑R DATE <br /> TANK W 39 �- <br /> R RINSED (Y METHOD <br /> I P64 y 1 ()C', -RINSE AMOUNT <br /> N ? RINSATE DISPOSAL SITE <br /> S <br /> E ,MANIFEST # <br /> -OR- OTHER <br /> V 'VAPORS PURGED Y N) METHOD . <br /> A AMOUNT UISED /S <br /> P L.E. L. READING AT REMOVAL (MUST BE (. <br /> ❑ �C+XJ <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL (STEEL., FIBERGLASS OTHER) TANK SIZE <br /> K C <br /> O TANK -CONDITION Goob; <br /> N POOR,' HOLESJ <br /> S PIPE MATERIAL (STEEL, IHERGLASS., OTHER) # FEET <br /> P T <br /> I WIPING CONDITION (GOOD POOR, HOLES) <br /> N <br /> G DEPTH SOIL 'TYPE OBSERVATION <br /> T SAMPLE # <br /> F <br /> I N �'� ' G✓/ �- I a 6 G� <br /> E K <br /> L <br /> D EXCAVATION SIZE: � " �' �, <br /> S x YDS OF SOIL: <br /> I A DEPTH SOIL..TYPE OBSERVATION <br /> N M P SAMPLE # <br /> S P I <br /> p L P. I <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION <br /> I X X YDS OF SOIL <br /> O H' DEPTH TO G. W. : <br /> N O: F T <br /> SAMPLING ME"CHOD <br /> G'` # OF HOURS SINCE - DEWATERING: <br /> O . - OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: <br /> VOLUME: <br />'H 23043 (10'/b9) DRAW SITE MAP ON REVERSE <br />