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(SHADED A 9 TO BE FILLED IN FOR THE y "RST TANK ONLY) <br /> G < OWNER NAME OWNER PHONE # <br /> E <br /> N r CONTRACTOR CON. PHONE# <br /> E 4. <br /> R SJLHD PERMIT # EPA # FIRE PERMIT # <br /> ff"Mm"ll iffi.4 <br /> L LO <br /> INSPECTOR �, DATE //�,.`��� TANK # 39 <br /> R RINSED (Y/N') METHOD 5 � RINSE AMOUNT <br /> I !/ <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED ("Y/N) METHOD AMOUNT USED sx� �UJO <br /> A <br /> P L.E.L . READING AT REMOVAL (MUST BE < 20%) C 10 <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANtt Fi '�' Rl:,i. STE , PIBE12GLi,�P�, :t; .: it.NK SIZE 4 00 o ' a{ <br /> K C <br /> / 0 TANK CONDITION (GOOD, POOR HOLES ) <br /> P N <br /> I S PIPE MATERIAL ,"(STEEL, FIBERGLASS, OTHER) # FEET A <br /> P T <br /> I PIPING CONDITION (GOOD,'' POOR, HOLES ) k- <br /> N _- <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> F TA ~� t /'^-c% o✓" A✓ rete r-is" e.m,., <br /> I N « <br /> E K <br /> L <br /> D EXCAVATION SIZE: X X YDS OF SOIL : <br /> S <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> N M P <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X X YDS OF SOIL <br /> I — <br /> O H DEPTH TO G.W. : FT SAMPLING METHOD <br /> N 2 <br /> 0 # OF HOURS SINCE DEWATERING: <br /> ❑O OTHER SAMPLE: A <br /> LABORATORY: ` ; L SAMPLERS NAME: . <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />