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PHS--EHD – UNDERGRA TANK CLOSURE/ABANDONMEN NSPECTION <br />(SHADED AREA TO BE FILLED IN FOR THE FIRST TANK ONLY) <br />"m <br />E <br />OWNER NAMEOWNER PHONE # <br />N <br />E <br />CONTRACTOR LL CON. PHONE# <br />R <br />SJLHD PERMIT # EPA # FIRE PERMIT # <br />A <br />INSPECTOR <br />DATE TANK # 39 <br />R <br />RINSED Y N) METHOD RINSE AMOUNT <br />z <br />RINSATE DISPOSAL SITE <br />N <br />S <br />MANIFEST # –OR– OTHER <br />E <br />V <br />VAPORS PURGED (Y/N) METHOD AMOUNT USED <br />A <br />_ <br />L. E. L. READING AT REMOVAL (MUST BE ( 20X) <br />P <br />COMMENTS �E <br />T <br />R <br />A <br />N <br />TANK MATERIALE , FIBERGLASS, OTHER) TANK SIZE <br />K <br />C <br />TANK CONDITION (GOOD, POOR, HOLE ) <br />/ <br />0 <br />N <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET---- <br />X <br />S <br />P <br />T <br />PIPING CONDITION (GOOD, POOR, HOLES) <br />I <br />N <br />G <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />F <br />I <br />E <br />A ; <br />N <br />Ks <br />`OM IrLA-1Cotter ­,�-h - J <br />c <br />TE <br />7��—� I <br />L <br />- <br />EXCAVATION SIZE: X X YDS OF SOIL: <br />D <br />S <br />I <br />A <br />DEPTH SOIL TYPE'OBSERVATION SAMPLE # <br />N <br />M <br />P <br />S <br />P <br />P <br />L <br />I <br />P <br />d <br />` <br />E <br />I <br />E <br />C <br />N <br />TRENCH DIMENSION X X YDS OF SOIL <br />T <br />G <br />I <br />H <br />DEPTH TO G. W.:{d FT SAMPLING METHOD -- <br />0 <br />N <br />2 <br /># OF HOURS SINCE DEWATERING : <br />G <br />O <br />OTHER SAMPLE: <br />LABORATORY: <br />77 <br />u 77 s <br />SAMPLERS NAME: �. <br />CLOSURE IN PLACE I <br />MIXTURE: <br />VOLUME: <br />EH 23043 (14/89) DRAW SITE MAP ON REVERSE <br />m <br />