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(SHADED Ai TO BE FILLED IN FOR THE `ST TANK ONLY) <br /> "pow \ •x �� <br /> G < OWNER NAME OWNER PHONE 9 <br /> E <br /> N < CONTRACTOR <br /> E xk' } CON. PHONEq i _ <br /> 1 ` �C 1'�, ` , <br /> R < SJLHD PERMIT Y EPA d FIRE PERMIT <br /> L <br /> A t <br /> . . <br /> INSPECTOR I DATE TANK Y 39 - <br /> R RINSED" (Y/N) C METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST @ <br /> -OR- OTHER <br /> VA VAPORS PURGED ((Y/N) METHOD +�( AMOUNT USED 1 j <br /> P L .E.L. READING AT REMOVAL (MUST BE < 20%) <br /> 0 <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL ,(STEEL, FIBERGLASS, OTHER) TANK SIZE lG <br /> K C <br /> / 0 TANK CONDITION ODPOOR, HOLES ) <br /> P N � <br /> I S PIPE MATERIAL 4'SEIR TFIBERGLASS, OTHER) R FEET <br /> P T <br /> I PIPING CONDITION (GOOD, POOR, HOLES ) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE I <br /> T <br /> F A <br /> I N � �� '�a--'z" 5 - -75 <br /> E K <br /> L <br /> D EXCAVATION SIZE: X ' X YDS OF SOIL : IC)C .- � � <br /> S- <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE q <br /> N M P <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 /> 0 H DEPTH TO G.W. : FT SAMPLING METHOD <br /> N 2 <br /> 0 It OF HOURS SINCE DEWATERING: <br /> OTHER SAMPLE: <br /> LABORATORY: � ' , / SAMPLERS NAME: n <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> DRAW SITE MAP ON REVERSE <br />