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'='` "• PHS—EHD <br /> UNDERt'^ IND TANK CLQSURE/ASANDQNZ - <br /> (SHADED AREA E FILLED IN FOR <br /> THE FIRS ' - INSPECTION �'" iJ <br /> I TANK (ONLY) J <br /> OWNER NAME 7 S. Acu <br /> .J DI+K OWNER p S�lc--t <br /> N CONTRACTOR HONE ## ] r G <br /> E W Q S Ge 0�_Q <br /> R RMIT <br /> T Con,. PNOY <br /> NE#,', �o <br /> f; SJLHD <br /> A EPA <br /> L FIRE PERMIT # <br /> I _ 4 <br /> INSPECTOR <br /> DATE TANK # ��g d. ! <br /> R RINSED _ S- _ i <br /> I /N) METHOD ~— <br /> t <br /> N �`� /c RINSE AMOUNT <br /> RINSATE DISPpggL <br /> S SITE f 9� sG <br /> t E MANIFEST <br /> OTHERVAPORS PURGED (y/N) METHOD <br /> GL..E. L. P AMOUNT USED <br /> Q READING AT REMOVAL (MUST BE ( 20%) <br /> T R COMMENTS <br />,N TANK MATERIAL ii <br /> C STEEL FIBERGLASS, I. <br />� O TANK CONDITION (GOOD, POOR, OTHER) TANK SIDE _ <br /> I <br />�. S I CHOLES) <br /> PIPE MATERIAL ( � <br /> T TEEL,' FIBERGLASS, <br />' OTHER) # <br /> PIPING f CONDITION (GOOD, POOR, HOLES) <br /> f DEPTH SOIL TYPE I{ f <br /> I T OBSERVATION i "- <br /> A <br /> N ,� / r 1 SAMPLE # <br /> ,. <br /> li J 4E�r <br /> EXCAVATION SI ii <br /> S ZE: 3yX 30' I <br /> A SO �� X YDS OF SOIL! _ <br /> DEPTH IL TYRE OBSERVATIODl-^ <br /> Ij <br /> M P � <br /> P I SAMPLE # <br /> I E <br /> N <br /> S TRENCH <br /> DIMENSION <br /> X X YDS OF <br /> H DEATH TD SOIL <br /> h G. W. e <br /> �'�-- FT SAMPLING METHOp <br /> 4 # OF HOURS SINCE /3• •�ss �P� <br /> DEWATERING; r <br /> I O OTHER SAMPLE! t <br /> LABORATORY: <br /> Se oex c r SAMPLcRS <br /> CLOSURE IN PLACE NAME: a '�'� sr,ti <br /> MIXTURE; �� Y <br /> 43 (I01$g) VQLLIME; <br /> DRAW SITE MAP <br /> ON REVERSE E . <br />