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PHS-EHD -- UNDE(')JUND TANK CLOSURE ASANDON�VT INSPECTION <br /> (SHADED AREA 1"0 BE FILLED IN FOR THE FIRST TANK ONLY) <br /> 0 01 11 1 <br /> ROMP, <br /> E OWNER- NAME OWNER PHONE # ' <br /> A . <br /> N CONTRACTOR CON. PHONE# <br /> E <br /> R SJLHD PERMIT # EPA # FIRE PERMIT # �/ <br /> A ti <br /> L <br /> J <br /> INSPECTOR DATE T NK # <br /> R RINSED Y/ ) METHOD "- RINSE AMOUNT <br /> I /riper <br /> SR I NSATE DISPOSAL SITE � G � <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED (YeV) METHOD <br /> A ��n AMOUNT USED <br /> P. L.-E. L. READING AT REMOVAL (MUST BE <br /> O l <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL ( TEEL, FIBERGLASS, OTHER) TANK SIZE <br /> K C l <br /> / 0 TANK CONDITION, (GOOD, F1QOF�, HOLES) E i �ftc;h+ <br /> J <br /> N (. �� ,S 'Ffi'1- 1` <br /> r S PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET ` <br /> NPIPING CONDITION (GOOD, OQR,)) HOLES) _ <br /> G DEPTH SOIL TYPE OBSERVATIO <br /> TSAMPLE # <br /> F A — SILT CZ/�• c <br /> I N �. S%cam L-14--22L <br /> K SrcT cc. T `T <br /> D S EXCAVATION SIZE: IL X 2C7' XYDS OF SOIL: <br /> I A DEPTH 'SOIL TYPE --OBSERVATION <br /> N M p SAMPLE # <br /> P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION <br /> I X X YDS OF SOIL <br /> 0 H DEPTH TO G. W. : c'.Ltv ; FT SAMPLING METHOD <br /> N <br /> G # OF HOURS SINCE DEWATERING: <br /> O OTHER SAMPLE: <br /> LABORATORY: `7 t <br /> SAMPLERS NAME: ' <br /> CLOSURE IN PLACE MIXTURE: <br /> X114 <br /> EH 22042 (10/69) DRAW SITE MAP ON REVERSE <br />