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PHS-EHD - UNDE- ND TANK CLOSURE/ABANDO _N <br /> (SHADED AREA � INSPECTION <br /> jE FILLED IN FOR THE FIh_ - , ANK ONLY) <br /> E ,� OWNER NAME OWNER PHONE # <br /> N . CONTRACTOR E <br /> <� n/��_ CON. PHONE# <br /> R SJLHD PERMIT # <br /> EPA # FIRE PERMIT # 13(a <br /> L . . <br /> J I <br /> INSPECTOR -Ci S DATE TANK # .39 - .... <br /> R RINSED hY)N) C1Gv METHO <br /> I l✓✓ a RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> E MANIFEST # <br /> -OR- OTHER <br /> AVAPORS PURGED QY N) METHOD tCr� AMOUNT USED <br /> p L.E. L. READING AT REMOVAL (MUST RE <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL (STEEL, FIBERGLASS, OTHER) TANK SIZE cl 3 a--- <br /> K C <br /> / 0 TANK CONDITION (GOOD, POOR, HOLES) ( r <br /> S PIPE MATERIALSTEEL FIBERGLA <br /> P T SS, OTHER) # FEE'( <br /> I PIPING CONDITION (GOOD POOR' <br /> G HOLES) ' <br /> n <br /> DEPTH SOIL TYPE OBSERVATION <br /> T SAMPLE # <br /> F A /a-( , - '4M c <br /> I N <br /> E K <br /> L i <br /> D EXCAVATION SIZE: <br /> S X X YDS OF SOIL: <br /> I A DEPTH SOIL TYPE OBSERVATION <br /> N M P SAMPLE # <br /> S P I i <br /> P L P <br /> E I E G- <br /> C N <br /> T G TRENCH D I MENS I ON ,3/ X l 20 X �,� <br /> I _]. YDS F SOIL <br /> 0 H DEPTH TO G. W. ; - '', I i <br /> N ? ------ FT SAMPLING METHOD <br /> 0 # OF HOURS SINCE DEWATERING: <br /> 0 OTHER SAMPLE: <br /> LABORATORY:Got �(`(\ PCZ. SAMPLERS NAME: L4 <br /> J <br /> CLOSURE IN PLACE MIXTURC: <br /> VOLUME: <br /> EH 23043 ( 10/89) DRAW SITE MAP ON REVERSE <br />