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ENVIRONMENTAL WELL,REMEDIATION COMPOUND,AND SITE INSPECTION FORM { Page <br /> I of <br /> INCIDENT# - �"/ `+1y - ADDRESS ��j' f(�CS Ra�+6r <br /> DATE: "1 J'� � yl CITY&STATE ./� r r"777CCCllI I <br /> Note Repairs Matle Photos of ii Repair Date i <br /> � Well labeled/, We 11 Cap Weil Patl/ - I <br /> WeItID petalled Explanation Maintenance Recommended Wall anal PM <br /> tdanway Cover,Type,Condition 8 Sae pa n[etl ,� {Gripper) Well Lock Condition SUReee i <br /> „ and Performed' Condition Initials <br /> :Properly' Condition Condition , <br /> alxv pncM1) <br /> aM _f f_ ntlpipe ush G P Y N G - R /G } R NL G P Y J <br /> !!,�I (W size(inch) `.J <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> size(inch) <br /> Slandpipe Flush G P Y N G R G R NL G P Y N <br /> $is.(Inch) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> Sim(Inch) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> see finch) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> alio pooh) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> St.finehl <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> sim Ones) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> srra(inch} <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> size pn<p <br /> Standpipe Flush G P Y N O R G R NL G P Y N <br /> TOTAL#CAPS REPLACED= =FAL#OF LOCHS REPLACED <br /> Conditldn <br /> of sell Boring Patches6 p A `7!-POOR,Bddng5NJeii lDs o[Locatlon Descriptidn: Y N <br /> ;AaanCanedMaditoring Wo0q" <br /> ,RemediSuch CampowrdTypaMondhlmHfTAnealnslde FmeigewyCd'ntsetW#o - Plistb594Compound Security %Ctoanblgf Repairs RewmhtaritleGand Contlua„(Q heck bozos thatipply)NA <br /> Building <br /> BuitdingvdFenceComp. G P N/0. G P lA Y N /A Y N <br /> Fenced Compound <br /> Trailer <br /> ConDrmDrums Photos n! cr Drvms -� <br /> Number of Doosthe UtalRovaal'the Lauelotl Correctly and ' Dnihrs Lbda[iE to Min - Rmo edrrom': <br /> Drum'CPnd(tiw Relatetl to Detolled Explanation of Any issues Resolvad .Cram <br /> Drams on-eto Sourcooftha Contents Writing Legible Snsineusintedemnee mt. <br /> Envlronmeninl Ceedidon vna stn in,nak j <br /> V <br /> Y N N/A Y N NIA G P NIA Y N Y N NW Y N <br /> G=Good(Acceptable) R=Replaced - All environmental wells and the remediation compound ware in good condition, <br /> P=Poor(needs attention) NL=No Lock Required locked,and secured upon my departure(unless otherwise noted above). <br /> N h An ra Wm etMr an ave n in heli VM a mwi ne to air /� ',t /( (('i(I� !^ fes'/tea/'/f` <br /> =emunewater meNteN,g wen coreR must be petaled and labele l m scruessee with appiitede reguladca, lit V,��t ( 1 e )1 1 / r <br /> Verska zs.M 2009 Print or type Name of Field Personnel&`Consultant Company <br />