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PHS-EHD - UNDERGROUND TANK CLOSURE/ABANDONMENT INSPECTION FO� <br /> (SHADED yAREA <br /> T•��OyByEFILLED <br /> � IN FOR THE FIRST TANK ONLY) <br /> y�/y <br /> E �7i�E 2 i G "7L7u�li u�i/ar'7u"/i� vJk�ia <br /> o o.- G/t 9SZ0.6' <br /> OWNER NAME r OWNER PHONE # <br /> E iul O —SP7� <br /> N CONTRACTOR <br /> E �QS �/� CON. PHONE# <br /> r <br /> R SJLHD PERMIT # A Z d/S3 FIREPERMIT # /SY5 6 <br /> A <br /> L <br /> INSPECT R DATE �� 9 TANK # 39 <br /> R RINSED Y N> METHOD <br /> I �' /C/NS G RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED ©/N) METHOD rJQ �Ge AMOUNT USED <br /> A <br /> P L. E. L. READING AT REMOVAL (MUST BE ( 20%) /. /-?I <br /> 0 SGJ /L G Di, Cst7 <br /> T R COMMENTS <br /> A a SO�/pie <br /> N <br /> K C TANK MATERIAL (STEEL FI SS, OTHER) TANK Z //00 <br />� <br /> / O TANK CONDITION (GOOD <br /> N POOR, HOLES) <br /> `x S PIPE MATERIAL (STEEL FIBERGLASS, OTHER) # FEE AI� <br /> P T r rN M <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> G T DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> F A UL <br /> I N od <br /> E K <br /> L <br /> D EXCRVATION SIZE: X �a X <br /> S YDS OF SOIL: <br /> I A DEPTH SOIL TYPE OBSERVATION <br /> N M P SAMPLE # <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X X <br /> I YDS OF SOIL <br /> 0 H DEPTH TO G. W. : FT SAMPLING METHOD <br /> N 2 <br /> 0 # OF HOURS SINCE DEWATERING: <br /> 0 OTHER SAMPLE: <br /> LABORATORY: <br /> lii9i✓bh//Pi / �D SAMPLERS NAMEyAl�R�P � <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> 23043 ( 10/89) DRAW SITE MAP ON REVERSE <br />