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Y ti ti �—---------....._�_lam•�� i,,�„� ��. •,- n..c ��, Ind G , ti OWNER NAME S A OWNER PHONE # / __----._..._..__..__._._..._........_..__...._......_.... . .... ......... N CONTRACTOR �� CON. PHONE# E R SJLHD PERMIT # EPA # FIRE DEPT A . ! -M' 4z SJLHD INSPECTOR TANK # 39 R RINSED (Y/LV) METHOD /u" RINSE AMOUN� 1 I - - �-- --- - -_-1_ �L...__._._.._. N RINSATE DISPOSAL SITE A_,Al S ------- - - ___ ....._...... ..........._..........._ ...__. _.__......... -- E MANIFEST # X/ :Al -OR- OTHER ;v/ _._ V VAPORS PURGED 7Y/N) METHODr.(-) USED A -� ------_ 1��iun'Tz P L .E.L . READING AT REMOVAL (MUST BE < -__-- 20%) A_, tA0 - -._..-_ T R COMMENTS A .-_......__..__. .._.._....._...._.. C N TANK MATERIAL ��TE�7 FIBERGLASS, OTHER)1 TANK SIZE K ._.............. - - / 0 TANK CONDITION (GOOD, POOR, MOLE ) I S PIPE MATERIAL ( E FIBERGLASS OTHER ) # FEET P T I PIPING CONDITION (GOOD,�'P00 , HOLES ) N -- - G DEPTH SOIL TYPE OBSERVATION _ - SAMPLE # _ -..._...._.._.......... F A -- - E K L -_...._.._.__..__.____... _.___._.__..._._.._...___ ._._._ I ... __ _..... D EXCAVATION SIZE: _-^�_--- I YDS OF SOIL : I A DEPTH SOIL TYPE OBSERVATION SAMPLE # N M P S P I .._........ ....... .-.-_........................ PL P -_ _-- -..._..-.-- - -........ ....._ __ __ ..... _. ....... _ .............. ...... E I LE C N T G TRENCH DIMENSIONS : I YDS OF SOIL : I 0 H DEPTH TO G.W. : FT SAMPLING METHOD N2 _-_.._._._.__.._._.._....... ...... .._---... ....___._._... ..__.........----.__.__--- 0 # OF HOURS SINCE DEWATERING : F_ol OTHER SAMPLE: J LABORATORY: - - SAMPLERS NAME: - _J CLOSURE IN PLACE I MIXTURE: - i VOLUME:- -_-� DRAW SITE MAP ON REVERSE