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PHS-EHD - UNDERGROUft•TANK CLOSURE/ASANDONMENT' ;'�ISPECTION <br /> /yyy (SHADED AREATO BE FILLED I N FOR THE FIRST TANK ONLY) <br /> OWNER NAME � OWNER PHONE # � y g3!- �,, f <br /> N CONTRACTOR 42 r� CON. PHONE# (-40C <br /> E , <br /> R SJLHD PERMIT # EPA # Ow 44P4. FIRE PERMIT # +, <br /> L <br /> INSPECTOR ` DATE 61�I�G1 TANK # ti9 gm�:� �, <br /> R RINSED 1 'N) METHOD ��( �Q��y RINSE AMOUNT 6 0,1 <br /> I <br /> N RINSATE DISPOSAL SITE �A GSL <br /> 5 <br /> ost— <br /> E MANIFEST # -OR- OTHER <br /> V VAPORS PURGE Y N) METHOD v_ AMOUNT USED <br /> A <br /> P L. E. L. READING AT REMOVAL (MUST RE <br /> 0 <br /> T R =ENTS <br /> A <br /> N TANK MATERIAL ESTE , FIBERGLASS, OTHER) TANK SIZE <br /> K C <br /> / 0 TANK CONDITION (GOOII OOR HOLES <br /> N <br /> S PIPE MATERIA EEL, )FIBERGLASS, OTHER) :J�FEET <br /> . r <br /> P T <br /> I PIPING CONDITION (GOOD a0 , HOLES) <br /> N <br /> G kAVATION <br /> TH SOIL TYPE OBSERVATION SAMPLE # <br /> T ( r 5z Ev. r1 L a'q �aN Y��l <br /> F A <br /> I NE KLD SIZE: X X YDS OF SOIL: <br /> S <br /> I A DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> N M <br /> S P I L 7 d rAlN A,i G d,L <br /> P L P <br /> E I E <br /> C N <br /> IT G TRENCH DIMENSION X X YDS OF SOIL <br /> II <br /> 0 H DEPTH TO G. W. : FT -T—SAMPLING METHOD <br /> N 2 <br /> G # OF HOURS SINCE DEWATERING: <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS SAMPLERS NAME: AfNAvRD <br /> CLOSURE IN PLACE MIXTURE: VOLUME: I <br /> 2ZO4L ( 10/89) DRAW SITE MAP ON REVERSE <br />