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PHS—EHD — UNDERNPUND TANK CLOSURE/ABANDON T INSPECTION <br />(SHADED AREA 1W BE FILLED IN FOR THE FIRST TANK ONLY) <br />E OWNER -NAME OWNER PHONE # <br />�c�t moo' 9l6� <br />N CONTRACTOR �� m°��l. / <br />E ! e�� e� �� � ����� � CON. PHONE# 7l6— 6Y —W -7-2— <br />R SJLHD PERMIT # EPA # C -710 <br />A FIRE PERMIT # <br />L <br />J <br />INSPECTOR DATE / 3 J TANK # 39 G- <br />R RINSED t /N) METHOD <br />I R I NSE:,AMOUNT <br />N RINSATE DISPOSAL SITE <br />E MANIFEST # <br />—OR— OTHER fi� s <br />V VAPORS PURGED (Y N) METHOD <br />A AMOUNT USED <br />P clo <br />L. E. L. READING AT REMOVAL ( MUST` BE < 0%) o` � <br />0 <br />T R COMMENTS <br />A peR r.f + t x rll��rPra� <br />N TANK MATERIAL STEEL FIBERGLASS, OTHER) TANK SIZE <br />K C 0100 <br />/ O TANK CONDITION GOOD, POOR, HOLES) <br />N o a <br />+' S PIPE MATERIAL STEE , FIBERGLASS, OTHER) # FEET <br />I PIPING CONDITION (GOOD, POOR, HOLES) <br />N <br />G DEPTH SOIL TYPE OBSERVATION <br />T SAMPLE # <br />FN °gym�' <br />E K <br />L <br />D EXCAVATION SIZE: X <br />S X YDS OF SOIL. - <br />I A DEPTH SOIL TYPE OBSERVATION a <br />ol <br />N M p SAMPLE # <br />S P I /tv Lie�P <br />P L P <br />E I E �a� <br />C N <br />T G TRENCH DIMENSION„___ X X <br />I .___ YDS OF SOIL <br />0 H DEPTH TO G. W.: FT <br />N �? SAMPLING METHOD <br />G # OF HOURS SINCE DEWATERING: <br />0 OTHER SAMPLE: <br />• LABORATORY:. <br />' � (� SAMPLERS <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />.H 22043 (10/89) DRAW SITE MAP ON REVERSE <br />