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I. <br />11 <br />P <br />I <br />N <br />G <br />F <br />L <br />D <br />I <br />N <br />S <br />P <br />E <br />C <br />T <br />I <br />0 <br />N <br />mr <br />PHS-EHD - UNDERGRD TANK CLOSURE/ABANDONMEINSPECTION <br />(SHADED AREA TOO FILLED IN FOR THE FIRST NK ONLY) <br />OWNER NAME OWNER PHONE # <br />CONTRA TOR <br />SJLH)D PERMIT # FIRE PERMIT # <br />INSPECTOR P <br />DATE <br />!TANK # 39 <br />R <br />I <br />RINSED dN) <br />METHOD ri <br />RINSE AMOUNT <br />N <br />S <br />RINSATE DISPOSAL <br />SITE <br />E <br />"k, <br />E <br />MANIFEST # <br />-OR- OTHER'Jjj <br />V <br />A <br />—i <br />VAPORS PURGED <br />N METHOD p)± <br />a <br />AMOUNT USED 15016S <br />P <br />0 <br />L. E. L. READ ING AT <br />REMO VAL (MUST <br />BE ( 20-A) NJV,) <br />OTHER SAMPLE: <br />R <br />5k- <br />COMMENTS vwe"�" <br />I cr(-/ <br />q , m-�) <br />TANK MATERIAL (STEEL, FIBERGLASS, OTHER) I TANK SIZE COD 6AL <br />C <br />P'rily I Ay\ A <br />0 TANK CONDITION (GOOD, POOR, 0 1 <br />N <br />S PIPE MATERIAL((STEELO FIBERGLASS, OTHER) # FEET <br />T <br />PIPING CONDITION (GOOD,00!� HOLES) "'WiA <br />(P cbyyo�-`� <br />D P H OI� TYPE (11 <br />S <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />�77777477 771 LL�5-1 <br />N <br />K <br />_J EXCAVATION SIZE: X Z61 X YDS OF SOIL: <br />LABORATORY: CW SAMPLERS <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 230437 (10/89) pRAW SITE MAP ON REVER�SE, tj wt (I oo a <br />0'u ( +5-vo <br />D' 4t ; <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />Y <br />P <br />E <br />TRENCH DIMENSION X X YDS OF SOIL <br />11 H <br />DEPTH TO G. W.: FT SAMPLING METHOD <br />a <br />0 <br /># OF HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: CW SAMPLERS <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 230437 (10/89) pRAW SITE MAP ON REVER�SE, tj wt (I oo a <br />0'u ( +5-vo <br />D' 4t ; <br />