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PHS-EHD - '' � <br /> UNDERGO' IND TANK CLOSURE/ABANDONM ` INSPECTION <br /> {SHADED AREA TG '�E FILLED IN FOR THE FIRS� V <br /> CNK ONLY) <br /> OWNER• NAME I <br /> OWNER PHONE # I. ' <br /> N r CONTRACTORi <br /> E CON. PHONE# <br /> R ,F SJLHD PERMIT # <br /> A , �, , EFA # FI[RE PERMIT #f <br /> L <br /> INSPECTOR .�kDATE TANK # I g 'k <br /> R RINSED Y N) METHOD � �l,c►-Q <br /> I I ; RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE PatMSpyZ_ f1 t <br /> S <br /> E MANIFEST # <br /> -OR- OTHER I <br /> V VAPORS PURGED METHOD <br /> A AMOUNT USED 93 {bs <br /> P L.-E.L. READING AT REMOVAL (MUST BE 2GX) �7 Z�o �z " Oa <br /> 0 l <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL STEE , FIBERGLASS, OTHER) TANK SIZE <br /> K C I � <br /> / 0 TANK CONDITION (GOOD, POOR, HOLES) <br /> k N I i <br /> .3 k <br /> i" S PIPE MATERIAL (STEEL FIBERGLASS, OTHER) I # FEET QV�it ,y , <br /> P T i� ' <br /> I PIPING CONDITI GOOD POOR, HOLES) ,C-�-rffl,,w� <br /> N _ /" necA- <br /> G DEPTH SOIL TYPE OBSERVATION � <br /> T <br /> 11 SAMPLE # G <br /> F p r <br /> IN <br /> E K <br /> L �I <br /> EXCAVATION SIZE: -X X J <br /> S YDS OF SOIL:,30 4J <br /> NM p DEPTH SOIL TY OBSERVATION <br /> I <br /> SAMPLE # <br /> S P i <br /> P L p <br /> E I E i1 II <br /> C N <br /> T GF <br /> TRENC DIMENSION X �_ X YDS OF SOIL <br /> I <br /> © H DEPTH TO G. W. : FT SAMPL I NG METHOD � <br /> N � i <br /> G # OF HOURS SINCE DEWATERING: <br /> O OTHER SAMPLE: <br /> LABORATORY: SAMPLCRS NAME: <br /> CLOSURE IN PLACE MIXTURE: j <br /> °� C',v Ls <br /> H 23443 V OLEJRIE: fj ►c� <br /> {10/89) DRAW SITE MAP ON REVERSE i �� <br />