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PHS-EHD - UNDERGRu ,,..k )TANK CL❑SURE/ABANDONMEN- PECTI❑N <br /> (SHADED AREA TO B I LLED IN FOR THE FIRST TA ONLY) <br /> OWNER NAME OWNER PHONE # <br /> E j <br /> N CONTRACTOR CON. PHONE# <br /> E <br /> R SJLHD PERMIT # EPA # FIRE PERMIT # <br /> L <br /> f <br /> INSPECTOR G,OoA- DATE TANK # 39 - r9�} � - VU <br /> R RINSED (Y/N) TM—ETH06 .T,J � —T—RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> HHE MANIFEST # --OR- OTHER <br /> 1. <br /> V VAPORS PURGED (Y/N) METHOD ppi.- AMOUNT USED "gyp fps f C1 <br /> A <br /> P L. E. L. READING AT REMOVAL (MUST BE < 20%) <br /> O <br /> T R COMMENTS <br /> A <br /> N TANK MATERIAL -C , FIBERGLASS, OTHER) TANK SIZE <br /> K C <br /> / O TANK CONDITION (GOD , (500 HOLES) <br /> t N <br /> S PIPE MATERIAL T , FIBERGLASS, OTHER) # FEET <br /> P T <br /> I PIPING CONDITION (GOOD �F'OOR HOLES) <br /> Ni <br /> G DEPTH SOIL TYPE OBSERVATION SAMPLE . # <br /> T <br /> F1- <br /> I N �� F <br /> E K <br /> L <br /> D EXCAVATION SIZE: X X YDS OF SOIL: <br /> S _ <br /> I AN[TRENCH <br /> EPTH SOIL TYPE, OBSERVATION . SAMPLE # <br /> N M <br /> S P <br /> P L <br /> E I C N <br /> T G DIMENSION X X YDS OF SOIL <br /> I <br /> 0 H DEPTH TO G. W. : FT SAMPLING METHOD <br /> N <br /> G # OF HOURS SINCE DEWATERING: <br /> QOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE. MIXTURE: VOLUME: <br /> i 231o437 ( lo/89) DRAW SITE MAP ON REVERSE <br />