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PHS-EHD - UNDERC UND TANK CLOSURE/ABANDONML-4T INSPECTION <br /> (SHADED AREA T('J'BE FILLED IN FOR THE FIRST TANK ONLY) <br /> OWNER NAME OWNER PHONE # <br /> E S <br /> N CONTRACTOR <br /> E CON. PHONE# <br /> R SJLHD PERMIT # <br /> A . ' EPA # FIRE PERMIT # 7b `�67 <br /> INSPECTOR <br /> R RINSED (Y N> METHOD RINSE HMUUNT <br /> I <br /> N RINSATE DISPDSAL SITE �m OLS u` <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS GORGED (Y/N) METHOD <br /> A <br /> (� AMOUNT USED a0 l S <br /> p L. E. L. READING AT REMOVAL <br /> 0 (MUST BE < 20%). <br /> y <br /> T R COMMENTS <br /> n <br /> N TANK MATERIAL (STEEL, FIBERGLASS, OTHER) TANK SIZE <br /> K C 1 1,0 0 <br /> / O TANK CONDITION (GOOD POOR, HOLES)41S L A-L��� �a�e �tilQ <br /> N �(LC�f/ <br /> S PIPE MATERIAL (STEEL FIBERGLRSS, OTHER) # FEE"fpiPit1 <br /> P T <br /> I PIPING CONDITION GOOD POOR, HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> F Al <br /> I N <br /> E K ) <br /> L <br /> D EXCAVATION S ZE: x X YDSS IL: <br /> ef <br /> s <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> wATERw0RK <br /> G CCHEMICA(•GEO)ECHNICAL•E _ <br /> NMRONMENigL <br /> X � x _, YDS OF SOIL <br /> CHLCKBATTpAM <br /> HDD <br /> Man <br /> Construction FT SAMPLING ME"f ager —'"-- <br /> WATERING: <br /> 1710 WIN SMEET <br /> E�=4LON <br /> CA 95320• (209)838-3507 <br /> SAMF'LCRS NAME: <br /> LABORATORY:—ID <br /> VOLUMC: <br /> cuosUliE 1N PLACE r�LxTu�(t <br /> EH 23043 (10/89) <br /> DRAW SITE MAP ON REVERSE <br />