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M. � SJLHD - UN"~RGROUND 'DANK CLOSURE/A4A`------4MENT INSJ'J LC'IUN r <br /> (SHADEL` i., A TO BE FILLED IN FOR Tr -a. IRST TANK: ONLY) " <br /> wil all mul-14 mm -T,'Pl=m. . . <br /> Y <br /> G OWNER NAME OWNER PHONE # <br /> E <br /> N i CONTRACTOR CON. PHONE ' ' <br /> E <br /> R SJLHD PERMIT I EPA I FIRE PERMIT; "11 <br /> L � �� : . <br /> INSPECTOR. 5DATE 1Z,7c' TANK 39 - I° (on <br /> R' RINSED N) METHOD RINSE AMOUNT uK� <br /> I <br /> N, RINSATE DISPOSAL SITE 7 <br /> S. <br /> E MANIFRST I -OR- .:OTHER <br /> A -T <br /> ~ - V VAPORS PURGED Y(�N) METHOD 'Vx,?.� l CE AMOUNT USED' <br /> P L.E.L. READING AT REMOVAL (MUST BE < 20%) — <br /> O` i <br /> T R COMMENTS <br /> A - <br /> N TANK MATERIAL TEE , FIBERGLASS, OTHER) TANK: SIZE � <br /> K C <br /> / 0 TANK CONDITION GOOD HOLES) � r �, <br /> P N <br /> I S PIPE MATERIAL STEEL FIBERGLASS, OTHER). # FEETI <br /> ' P T <br /> I PIPING CONDITION (GOOD, OOR)., HOLES) <br /> N <br /> G DEPTH SOIL TYPE OBSERVATION , SAMPLE # <br /> T ' <br /> F A 1-3 ow <br /> I N E .I Lt Oboe- <br /> L <br /> D EXCAVATION SIZE: J( 28 X lam` YDS OF SOIL: <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> N M P � <br /> S P I � . <br /> P L' P <br /> E <br /> C N F .k <br /> T G TRENCH DIMENSION X X YDS OF SOIL <br /> O H DEPTH TO C.W. : FT SAMPLING METHOD <br /> N 2 <br /> 0, 1 OF HOURS SINCE DEWATERING:- <br /> , <br /> OTHER SAMPLE: <br /> LABORATORY: E^"�'�4"�"" SAMPLERS 'NAME: <br /> CLOSURE IN PLACE MIXTURE: s VOLUME:. g <br /> Ell 2:1 01'1(7/88) DRAW SITF, MAP ON REVERSE <br /> '` <br />