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PHS--EHD - UNDERGROL TANK CLOSURE/ABANDONMENT .NSPECTION <br /> (SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br /> E OWNER NAME OWNER PHONE # 76 <br /> f3 <br /> N CONTRACTQR <br /> E6 .�,,, CGP. F�HONE# <br /> R % SJLHD PERMIT # EP c# 002,7776 <br /> A • �� ,/ / FIRE PERMIT # o- D -J- <br /> INSPECTOR .11 DATE TANK # <br /> R RINSED (Y/N) ,� METHOD �!/irrc:,r <br /> I 11+,, i 171y RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S r <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGED 4 N) METHOD ' Y. 1`< e , <br /> A , AMOUNT USED - �' �' - <br /> P L. E. L. READING AT REMOVAL (MUST BE ( AUX) �� v r,-r( .a. . <br /> O _ <br /> T R COMMENTS <br /> N TANK MATERIAL " STEE , FIBERGLASS, SIZE OTHER) TANK S <br /> K C r <br /> / O TANK CONDITION (GOOD POOR OLEO EJ j <br /> • S PIPE MATERIAL (STEEL, FIBERGLA <br /> P 'f SS,. OTHER) # FEET <br /> _ <br /> I PIF-ING CONDITI01 (G <br /> N OOD, POOR, HOLES) <br /> G DEPTH SOIL TYPE OBSERVATION <br /> T SAMPLE # <br /> F q <br /> I N . <br /> E K <br /> L <br /> D EXCAVATION SIZE: <br /> S X X YDS OF SOIL: <br /> IA DEPTH SOIL TYPE OBSERVATION <br /> N M P SAMPLE # <br /> S P I <br /> F' L P <br /> E I E <br /> C N <br /> T G TRENCH DIMENSION <br /> I X X YDS OF SOIL <br /> 0 H DEPTH TO G. W. : FT <br /> N SAMPLING METHOD <br /> 0 # OF HOURS SINCE DEWATERING: <br /> 0 OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: <br /> VOLUME: <br />'H 23043 ( 10/89) DRAW SITE MAP ON REVERSE <br />