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6JLl1U - UNDE"GRUUND TANK CLOSURE/ABANDONMENT INSPECTION <br /> (SHADED ARE TO BE FILLED IN FOR THE F: 'T TANK ONLY) <br /> . .4 . . <br /> - Hwy S S <br /> G OWNER (NAME <-IA OWNER PHONE # <br /> E <br /> N < CONTRACTOR "S CON. PHONE# '5i ) gZ <br /> E <br /> R SJLHD PERMIT # EPA # FIRE PERMIT # <br /> A <br /> L _ <br /> ri <br /> INSPECTOR ,, ,j I DATE/p j p TANK # 39 <br /> R RINSED (Y N) METHODo RINSk'IAXOUNT <br /> I <br /> N RINSATE DISPOSAL SITE /J/,4 <br /> S <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED (Y N) METHOD - AMOUNT USED ; <br /> A <br /> P L .E.L. READING AT REMOVAL (MUST BE < 20%) ,�,/,� <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERiALP ' L, FIBERGLASS, OTHER) TANK SIZE UD U VC <br /> K C <br /> / O TANK CONDITION (GOOD, 00 , HOLES ) <br /> P N <br /> I S PIPE MATERIAL STE FIBE GLASS, OTHER) # FEET��� (4 <br /> P T �- <br /> I PIPING CONDITION (GOOD, POOi, HOLES ) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T t5t <br /> F A <br /> I N <br /> E K <br /> L <br /> D EXCAVATION SIZE: X X YDS OF SOIL : <br /> S- <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> N M P N C. <br /> S P I <br /> P L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION X X YDS OF SOIL <br /> I <br /> N <br /> 0 # OF <br /> EHSAMPLING METHOD <br /> HOURS SINCE DEWATERING; <br /> ❑O OTHER SAMPLE: <br /> HlLABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />