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PHS-EHD - UNDJIOUND TANK CLOSURE/ABANDQ&ENT INSPECTION <br />(SHADED ARE 0 BE FILLED IN FOR THE FlW TANK ONLY) <br />"F` <br />a Of All, 11, YA IMF! vo W, <br />T F <br />A <br />IN <br />K c <br />1 c <br />2 <br />S <br />P I <br />I <br />IN <br />G <br />F <br />I <br />E <br />L <br />D <br />IS <br />N M <br />S P <br />P L <br />E I <br />C N <br />INSPECTOR C DATE i fic TANK # 39 -L.2- <br />I RINSED 09N) METHOD RINSE AMOUNT <br />4 RINSATE DISPOSAL SITE <br />I <br />3 <br />7 MANIFEST # -OR- OTHER <br />VAPORS PURGED O(Y N) METHOD AMOUNT USED <br />L.E.L. READING AT REMOVAL (MUST BE 20%) <br />I -COMMENTS <br />TANK MATERIAL �-E FIBERGLASS, OTHER)_ TANK SIZE <br />000 <br />TANK CONDITION (GOOD, POOR, HOLES) <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br />RINSED <br />NSED <br />R I NSATE <br />MANIFEST <br />cr <br />PIPING CONDITION (GOOD, POOR, HOLES) <br />T T DEPTH SOIL TYPE OBSERVATION w�) SAMPLE # <br />A -77- <br />N vy-- <br />K A 01V(fl-4 lu- 0 % <br />"^%MVPillulN 514L: -.jL x <br />P I DEPTH SOIL TYPE OBSERVATION <br />I <br />P <br />E <br />T G TRENCH DIMENSION X _ X YDS OF: SOIL <br />I <br />0 HDEPTH TO G. W.: --- F- SAMPLING METHOD <br />N 2 <br />0 # OF HOURS SINCE DEWATERING: <br />2 <br />PDTE <br />0 <br />0 OTHER SAMPLE: <br />.J <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23043 (10/89) DRAW SITE MAP ON REVERSE <br />SAMPLE # <br />OWNER NAME <br />OWNER PHONE # <br />- <br />CONTRACTOR <br />01 <br />CON. PHONE# <br />miZe <br />SJLHD PERMIT # <br />FIRE <br />PERMIT # <br />• <br />1.11pl�wil.lil-11.1uti.11"..,..,"---� ... ................ .. <br />., ... ....... W. <br />"I Y% g '/v *,p <br />, <br />r a <br />yp <br />MON11 <br />T F <br />A <br />IN <br />K c <br />1 c <br />2 <br />S <br />P I <br />I <br />IN <br />G <br />F <br />I <br />E <br />L <br />D <br />IS <br />N M <br />S P <br />P L <br />E I <br />C N <br />INSPECTOR C DATE i fic TANK # 39 -L.2- <br />I RINSED 09N) METHOD RINSE AMOUNT <br />4 RINSATE DISPOSAL SITE <br />I <br />3 <br />7 MANIFEST # -OR- OTHER <br />VAPORS PURGED O(Y N) METHOD AMOUNT USED <br />L.E.L. READING AT REMOVAL (MUST BE 20%) <br />I -COMMENTS <br />TANK MATERIAL �-E FIBERGLASS, OTHER)_ TANK SIZE <br />000 <br />TANK CONDITION (GOOD, POOR, HOLES) <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br />RINSED <br />NSED <br />R I NSATE <br />MANIFEST <br />cr <br />PIPING CONDITION (GOOD, POOR, HOLES) <br />T T DEPTH SOIL TYPE OBSERVATION w�) SAMPLE # <br />A -77- <br />N vy-- <br />K A 01V(fl-4 lu- 0 % <br />"^%MVPillulN 514L: -.jL x <br />P I DEPTH SOIL TYPE OBSERVATION <br />I <br />P <br />E <br />T G TRENCH DIMENSION X _ X YDS OF: SOIL <br />I <br />0 HDEPTH TO G. W.: --- F- SAMPLING METHOD <br />N 2 <br />0 # OF HOURS SINCE DEWATERING: <br />2 <br />PDTE <br />0 <br />0 OTHER SAMPLE: <br />.J <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23043 (10/89) DRAW SITE MAP ON REVERSE <br />SAMPLE # <br />