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PHS—EHD — UNDERCOUND TANK CLOSURE/ABANDONMOT INSPECTION <br />(SHADED AREA TU BE FILLED IN FOR THE FIRST TANK ONLY)t)j-#415 <br />- — - — ------ ------------ ... - - q ('� <br />OWNER, NAME <br />OWNER PHONE # <br />E <br />N ..CONTRACTOR CON. PHONE# <br />E <br />R SJLHD,PERMIT # EPA # FIRE PERMIT # <br />A. <br />L <br />INSPECTOR DATE 11 TANK It 39 <br />R <br />1 <br />RINSED N) <br />METHOD <br />12 1 RINSE AMOUNT <br />4L" <br />N <br />-- <br />RINSATE DISPOSAL SITE few I <br />E <br />MANIFEST # -OR- OTHER <br />V <br />A <br />v I <br />VAPORS PURGED (VN)ETHOD <br />-rm <br />-D <br />AMOUNT USED <br />I <br />Pa <br />L.E.L. READING AT REMOVAL (MUST BE < 0%) <br />T <br />R <br />COMMENTS <br />A <br />N <br />K <br />c <br />TANK MATERIAL (STEEL, FIBERGLAS lll� OTHER) TANK SIZE <br />0 <br />TANK CONDITIONPOOR, HOLES) A45 Obv-®c) <br />�OD <br />N <br />P <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # - FEET <br />I <br />PIPING CONDITION (GOOD, POOR, HOLES) <br />N <br />G <br />T <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />F <br />A <br />I <br />E <br />N)0 <br />K <br />A)o c <br />L <br />0 <br />EXCAVATION SIZE: x X L <br />S <br />I <br />YDS OF SOIL: <br />I <br />N <br />A <br />m <br />P <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />S <br />p <br />I <br />P <br />L <br />P <br />E <br />I <br />E <br />C <br />T G TRENCH DIMENSION X <br />I X YDS OF SOIL <br />O H DEPTH TO G. W.: <br />N 2 SAMPLING METHOD <br />0 # OF HOURS SINCE DEWATERING: <br />0 OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: - ME VOLUME: <br />EH 23043 (10/89) DRAW SITE MAP ON REVERSE <br />