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PHS-EHD - UNDE(�JUND TANK CLOSURE/ABANDON.-NT INSPECTION <br /> (SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br /> LZ ,7j <br /> OWNER NAME OWNS PHONE # (p7�'5�) IPA <br /> N CONTRACTOR CON. PHONE# (� <br /> R SJLHD PERMIT # �x <br /> A • , EPA # FIRE PERMIT -# ��77`•yi/�in,.Sif� <br /> L . ; . <br /> a <br /> INSPECTOR ��. DATE /j Z �d ANK # .39 - - <br /> R LRINSED (9N) ' METHOD R I NSE <br /> rrl;c•G i J � <br /> N RINSATE DISPOSAL SITE <br /> S r'o, <br /> ��; x <br /> E MANIFEST # <br /> -OR- OTHER <br /> V VAPORS PURGED �)N) METHODrL J AMOUNT USED <br /> P L.E. L. READING AT REMOVAL (MUST B ( 20:x) <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL STEEL FIBERGLASS, OTHER) TANK SIZE Jj�� S <br /> K C <br /> / 0 TANK CONDITION (GOOD, 'POR } HOLES) <br /> N r�f� Si G7l Q if�'c: <br /> S PIPE MATERIAL 4jEEFIBERGLASS, THER) # FEET 5 ` <br /> P, T <br /> I <br /> POOR HOLE ) <br /> PIPING CONDITION (GOOD <br /> N , <br /> G DEPTH SOIL TYPE OBSERVATIO14 <br /> T SAMPLE # <br /> I N _ .�� <br /> E K i3 51 L'T- <br /> L <br /> EXCAVATION SIZE; <br /> S X -��X YDS OF SOIL: `1 - <br /> I A DEPTH I SOIL TYPE OBSERVATIO <br /> N M p SAMPLE # <br /> S G I 1 ,� <br /> E I E f <br /> C N <br /> T G TRENCH D IMENSIONr X X <br /> I YDS OF SOIL r <br /> 0 H DEPTH TO G. W. : n c <br /> N 'n �vC FT SAMPLING METHOD <br /> 0 # OF HOURS SINCE DEWATERING: <br /> o OTHER SAMPLE: <br /> w LABORATORY; SAMPLERS NAME; iry. <br /> CLOSURE IN PLACE MIXTURE: /„/f+ VOLUME: <br /> ,,j <br /> EH 22043 ( 10/89) DRAW SITE MAP ON °R VERSE <br />