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PHS-EHD - UNDER( BUND TANK CLOSURE/ABANDONP T INSPECI-101v Pat <br /> (SHADED AREA Tu BE FILLED IN FOR THE FIRST" TANK ONLY) <br /> OWNER NAME <br /> OWNER PHONE # <br /> E „ <br /> N l CONTRACTOR CON. PHONE# i <br /> E y <br /> Rl SJLHD PERMIT # EPA # FIRE PERMIT # <br /> A ' r <br /> L <br /> J <br /> INSPECTOR �,' �: DATETANK # ?.9 <br /> R RINSED �Y N) METHOD ' <br /> I RINSE AMOUNT <br /> N RINSATE DISPOSAL SITES <br /> E MANIFEST # � ? -OR- OTHER _ <br /> V VAPORS PURGED ®N) <br /> AJ ,C�ETHOD <br /> i ( �i ( AMUUNT USED <br /> Yz Q <br /> P L. E. L. READING AT REMOVAL (MUST BE ( C20%) <br /> 0 <br /> TR COMMENTS <br /> A <br /> NFF <br /> ANK MATERIAL TEFL, FIBERGLASS, OTHER) TANK SIZE <br /> K <br /> ANK CONDITION (GOOD, <br /> N POOR OLES) <br /> j a <br /> S PIPE MATERIAL (STEEL,Q l 5t <br /> T , LASS;--,,OTHER) # FEET <br /> I PIPING CONDITION (GOOD, POOR, HOLES) <br /> N <br /> GFPEX <br /> SOIL TYPE OL;SERVATION SAMPLE # <br /> F C L� 'ni _ _ <br /> E L <br /> D ON SIZE: X X YDS OF SOIL: <br /> S <br /> I A DEPTH SOIL TYPE OBSERVATION <br /> N M P SAMPLE <br /> S P I < <br /> P L P <br /> E I E <br /> --------------- <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 <br /> C) # OF HOURS SINCE DEWATERING: <br /> 0 OTHER SAMPLE: <br /> LABORATORY: N F-T— SAMPLERS NAME : <br /> CLOSURE IN PLACE MIXTURE: <br /> VOLUME: <br /> EH 'L2,31043 ( 10/69) DRAW SITE MAP ON REVERSE <br />