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UMDERGRUUNL 'TANK CLOSURE/A4ANDOPMENT INSPECTION <br /> (SHADED AR" '.TO BE FILLED IN FOR THE F �` T TANK ONLY) <br /> 4 <br /> Cx�A S To cf n_� <br /> G OWNER NAME OWNER PHONE # j <br /> N CONTRACTOR UtO 0A- c O�� CON. PHONE# �s <br /> E <br /> R � SJLHD PERMIT # EPA # FIRE PERMIT # <br /> A <br /> L <br /> INSPECTORflviLfl DATE t0 �� � TANK # . 39 - lf2-�;L- - 000.E <br /> R RINSED (Y N)` METHOD RINSE AMOUNT <br /> r N RINSATE DISPOSAL,SITE : ..'. <br /> S A <br /> E `MANIFEST # --OR- OTHER <br /> l; <br /> V VAPORS PURGED (YIN) METHOD AMOUNT USED <br /> A <br /> P L.E.L. READING AT. REMOVAL (MUST .BE < 20%) - - - <br /> 0 <br /> T R COMMENTSF . <br /> A x <br /> 1 N TANK MATERIAL STEEL, FIBERGLASS, OTHER) TANK SIZE , <br /> K C UU <br /> / 0 TANK CONDITION GOOD, POOR, HOLES) <br /> P N <br /> IJT <br /> PIPE. MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> P h <br /> I PIPING 'CONDITION - (GOOD, POOR, HOLES) 3 <br /> N <br /> G DEPTH SOIL TYPE OBSERVATLON SAMPLE # <br /> T -r <br /> F A flti �1 No ,,� # <br /> I N <br /> E K' <br /> L ,D EXCAVATION SIZE: X { X ' S� YDS OF SOIL: <br /> S_ <br /> I A DEPTH SOIL -TYPE OBSERVATION° SAMPLE # <br /> S P I <br /> P L P - <br /> E I E <br /> i C N e <br /> 1 X YDS OF SOIL rk eve f� <br /> T G TRENCH DIMENSION X e� <br /> I <br /> 0 H DEPTH TO G.W. : FT SAMPLING METHOD t <br /> N 2 <br /> 0 # OF HOURS SINCE DEWATERING: <br /> Ell <br /> OTHER SAMPLE: <br /> LABORATORY: _ SAMPLERS NAME: <br /> a CLOSURE IN PLACE MIXTURE: �y ��� VOLUME: <br /> i <br /> y DRAW SITE MAP ON REVERSE <br /> Y Ji <br />