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r 5JLt1U — UNDWROUND TANK CLOSURE/ABANDGMMENT INSPECTION <br /> (SHADED AR,._. TO BE FILLED IN FOR THE � ST TANK ONLY) <br /> N�y� ,c(g95 Al TH. <br /> G < OWNER INAMEVUh;&/� / � OWNER PHONE # <br /> E iv <br /> ECONTRACTOR CON. PHONE# <br /> R SJLHD PERMIT # EPA # Da / FIRE PERMIT # ��( -oY <br /> A ' <br /> INSPECTOR h �—/ DATE & # 39 <br /> R RINSED (Y ) METHOD --TlsE- RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED Y N) METHOD <br /> A AMOUNT USED <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20'3) <br /> 0 <br /> T R COMMENTS <br /> A <br /> K C TANK MATERIAL (STEE , FI GLASS, OTHER) TANK SIZE /0[y <br /> / 0 TANK CONDITION (G OOR HOLES) gv'iG�P� <br /> P N <br /> I S PIPE MATERIAL (STEE , FIBERGLASS, OTHER) # FEET <br /> P T <br /> I PIPING CONDITION (GOOD, R HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> F A o No <br /> I N S1 t " <br /> E K rt° CL'L ti <br /> L �d <br /> DS EXCAVATION SIZE: X X YDS OF SOIL: `_W S3 <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> N M P <br /> S P I <br /> P L P S <br /> E I E <br /> C N C <br /> T G TRENCH D MENSION X X YDS OF SOIL 52, 4'5 C ✓ <br /> I <br /> 0 H DEPTH TO G.W. : NIS / FT SA PL NG METHOD ) <br /> N 2 logd sc,reedI't N. <br /> 0 # OF HOURS SINCE DEWATERING: <br /> OTHER SAMPLE: i <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: l—k VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />