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SJLHD — UN _?RGROUND TANK CLOSURE/AI(AN JMENT IN5YEl:'P1UN <br />(SHADED )tiiA TO BE FILLED IN FOR THE r`IRST TANK ONLY) <br />uicnw S P; MAY ON REVERSE•. <br />� J'�f� %% 1�I/]I�/l•ll.�l.L ll <br />I• <br />l.l�llDi� <br />���Y�J��1�iOII,�c l•/`�, b• �� <br />�/( F C'I / 1�.1Y Y i/Yl #�n �%�"� <br />L��L.ID <br />N N C lH/�![ S��C <br />G OWNER NAME p ./ <br />E /�E 4 LUa EICra G/ cJi/ <br />OWNER PHONE Y <br />ci i6- is/—/!UU <br />N CONTRACTOR <br />E vw,� COunjr <br />CON. PHONEY <br />MI6-3`ia lY6o <br />R SJLHD PERMIT Y EP Y FIRE PERMIT Y <br />������������ <br />` y� y� y� <br />L fN�`71C��`'�"y����L6SUlt��. . ."�. .t..i.... <br />INSPECTOR 6) J Z DATE jOIS/ �% TANK Y 39 — — <br />R RINSED (Y/N) METHOD <br />I RINSE AMOUNT <br />N RINSATE DISPOSAL SITE <br />S <br />E MANIFEST Y —OR— OTHER <br />V <br />A <br />VAPORS PURGED (Y/N) <br />METHOD <br />AMOUNT USED <br />P <br />L.E.L. READING AT REMOVAL (MUST BE < 20%) <br />0 <br />T <br />R <br />COMMENTS <br />A <br />N <br />K <br />C <br />TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br />TANK SIZE <br />/ <br />0 <br />TANK CONDITION (GOOD, POOR, HOLES) <br />P <br />N <br />I <br />P <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br />Y FEET <br />I <br />PIPING CONDITION (GOOD, POOR, HOLES) <br />N <br />G <br />DEPTH <br />SOIL TYPE OBSERVATION <br />SAMPLE Y <br />T <br />F <br />A <br />I <br />N <br />E <br />K <br />L <br />D <br />EXCAyAT X <br />SOIL: <br />I <br />N <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />MPLE Y <br />S <br />P <br />P <br />L <br />P <br />t7G rS� L `M <br />L S <br />E <br />I <br />E <br />C <br />N <br />T <br />I <br />G <br />TRENCH D ON X X lzL <br />YDS OF SOIL <br />0 <br />N <br />H <br />2 <br />DEPTH TO C.W.: FT -SAMPLING METHOD <br />0 <br />Y OF HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: CJ`7emPc j SAMPLER " r <br />�"uF �rcce S NAME:Geo. CUi�uev <br />CLOSURE IN PLACE MIXTURE:. <br />VOLUME: <br />uicnw S P; MAY ON REVERSE•. <br />