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ENVIRONMENTAL WELL,REMEDIATION COMPOUND,AND SITE INSPECTION FORM /'� nq Page_L of i <br /> INCIDENT# �r '�J'U'3y ADDRESS ca <br /> �,yYy Z,A(� i �h,£Pl /?, <br /> DATE: /_ ,(f 7J '�'BIY CITY$STATE 1�.._vV�(�„��� lr <br /> W -'a Opts ryatlons Ul3an(yR[vh1 ; Nate Repairs N"de Photos of Repair Date' <br /> Wdi1 ID > t"IBg CahBledy Wait ap Weli Pad J Detalled Explanation of Maintenance Recommended ,Well and Pm' <br /> MBn4w7 <br /> Cove[Typ'e Gpgd$ion.$:Sae Pa'Inted '(GtlppBY) Weli LbcH Contldion Suifaee :and Pertonned Cpntlltion tmtials <br /> > property" ,...ConftHbrt, Cdriditlon l <br /> sue(hchl �rouU� lJlEli( 4l` y ly <br /> 13tandpipe <br /> Flush G P b Y GN R © R NL P lJ <br /> 7 t sue(iuh) <br /> Flush G P Y N G R GR NL G P YNsim(Inch) <br /> F;tush P Y N G R G R NL G P Y N <br /> 91ze(inch) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> sue(inch) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> sue(mch) <br /> Standpipe Flush G p Y N G R G R NL G P Y N <br /> 9lze(invh7 <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> sue 0,,0) <br /> Standpipe Flush G P. Y N G R G R NL G P - Y N <br /> sue then) <br /> Standpipe Flush G P Y N G R G R NL G P Y .. N <br /> sue(mch) <br /> Standpipe Flush G P Y N G R G R NL G P Y N <br /> sru OMM1I <br /> Standpipe Flush G P Y N G R G R NL 6 P Y N <br /> TOTAL#CAPS REPLACED 0 =TOTAL#OF LOCKS REPLACED <br /> Contlitlop ofSptl Bedri'g Patefids;tir G P I IE.P.00 Bodnd e1f10aCr Location 0ascription: V N <br /> ,.I. "...".... Motuloring Wells. ;, ,*.: <br /> RemeGfationt:ompouhlYype IFtlndldon ofEneloosure CondiF)onoT!}reYlnsida Compotind Sacudty )'EmargetuyCohtactlnf° ;'CleanlnyfRepairsReeommentlgd hntl Conducted Gootlldett PPoWteiz �' <br /> (Ci ecktmxtlsfhstapplyl `' (tile <br /> ._. .. . ... .. .:. n.. -. <br /> NA <br /> Building ��� <br /> Bu <br /> Funded <br /> C mco Comp. G p N/A G P WA G P �...�' Y N WA Y <br /> Fanud Compountl v' <br /> Trailer <br /> ( COMimf Onrms : i Photos c( path'arnms' <br /> Numhei of Does the Lnbel(2oveal the labotetliCormady and' ' Ommsi:odated m-Mln. D <br /> led ta' Ex laoatlon dtAn IsgUes Resolved ' "Dram: Remolted(rdm5 <br /> DNmS ClbSIW Source of Na Contents W�ldag Legible Onim Cundlt(on :'Roloted to P. Y sim <br /> Ruelnass lnlerfnc <br /> er¢ e Condition <br /> -• ,:: aFAll lien- <br /> . 1::i .> ... . .,.:' ;' •: ,. .." ., ..,....� <br /> {f Y , N NI Y N N!A G P N1A Y N Y N NIA Y <br /> G=Good(Acceptable) R=Replaced All environmental wells and the remadiaffen compound were in good condition, <br /> P=Poor(needs attention) NL=No Look Required locked,and secured upon my departure(unless otherlelse noted above). <br /> eteAlrrc oirsaM1cr mnn loe4ca d ul eM11 PMa , i rloilem it //�I�p�,�,� (�j�/I/j� �j/(}�,.(�. <br /> •=(,eundwale,MoWtogrg Wog m must be peinled and uWad ir.s dam th*ocebla regulations. r 1�/ �#rr�'/ r "J%"' y %` <br /> Version zd,harm zom Pont ortype�Na eo Ftaid Personnel&C sullant Company <br />