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PHS-EHD - UNDEROUND TANK CLOSURE/ABANDONIAT INSPECTION <br /> (SHADE,yD�/ AREA TJ BE FILLED I,yN� FOR THE ,yFIRST <br /> TANK <br /> py ONLY) <br /> Jv � � ' ' <br /> � r i aJ�d1' a i <br /> W i <br /> -t 1 4 v Y <br /> , <br /> i OWNER NAME OWNER PHONE # Y3 _SG 6 <br /> N CONTRACTOR CDN. PHONE# <br /> E jZoc_441� P3.33 � <br /> R SJLHD PERMIT # EPA # C_Ac 600ns VFIRE PERMIT # 0/,6 ;�- <br /> L <br /> I NSPECTOR 5,.&4, H. �,w DATE z-12- 9U TANK # 39 - /206 - og <br /> R RINSED (YA�@ METHOD A-14 RINSE AMOUNT g' <br /> I � <br /> N RINSATE DISPOSAL SITE fl, <br /> S <br /> E MANIFEST # �le�5� -OR-- OTHER <br /> V VAPORS PURGED Y N) METHOD <br /> A AMOUNT USED <br /> F' L. E. L. READING AT REMOVAL (MUST BE < 20%) <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL (ST EE FIBERGLASS, OTHER) TANK SIZE <br /> K C _ !0, 006 G <br /> / 0 TANK CONDITION (GOOD, (POD HOLES) <br /> N <br /> A S PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEE-r M1"0" gs�w_ "c1 <br /> P 7 <br /> I I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> G T DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> F <br /> I N <br /> K <br /> L <br /> D EXCAVATION SIZE, 20 X X <br /> S ,L_ YDS OF (SOIL: <br /> I A DEPTH , SOIL TYPE " OBSERVATION SAMPLE # <br /> N M P <br /> S P I <br /> P L F f ` <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X X YDS OF SOIL <br /> I r_.._ <br /> O H DEPTH TO G. W. : <br /> N ..._.. W._ FT c,.�AMPL I NG ME-f HDD <br /> 0 # OF HOURS SINCE DEWATERING: <br /> O OTHER SAMPLE: <br /> LABORATORY.- - <br /> SAMPLERS NAME: � <br /> _r./i:=zs, J ;ti: r� u�iv �e7/c.✓�3 �i1as� <br /> CLOSURE IN PLACE MIXTURE: / VOLUME: Cf <br /> EH 23043 ( 10/89) DRAW SITE MAP ON REVERSE <br />