HomeMy WebLinkAbout21E document 2021- - 1160 GREAT POND ROAD0
JOB NAME: i1 �1 m Is '� CUSTOMER PHONE # - � _1 -1 �
SITE ADDRESS:
CITY: �� �i ��� STATE: ft)R _ZIP CODE:
Within 24 hours after the removal of a UST the owner/operator shall measure fur the presence of a release of oil or hazardous materials to the
environment where contamination is most lkel y to be present ou the situ
HOMEOWNER/BUSINESS OWNER QUESTIONS
❑ TYPE OF SITE (CIRCLE ONE)
SINGLE FAMILY RESIDENCE MULTI -FAMILY RESIDENCE
❑ UST AGE: & &_YEARS OLD
❑ UST SIZE f tr "0 e GALLONS
❑ UST FUEL TYPE (CIRCLE ONE)
FUI-L O_Lj GASOLINE
❑ IS T Pr1I5 USE? (CIRCLE ONE)
YES NO WHY?.
OTHER
BUSHES TYPEC
YEAR INSTALLED
HAVE THERE BEEN ANY ERRATIC CHANGES IN YOUR USAGE OR BILL?
60 YES EXPLAIN
LAST FILL DATE AMOUNT OF LAST FILL
HAS YOUR TANK EVER BEEN RELINED?
l::Q YES WHY?
HAVE THERE BEEN ANY SPILLS IN THE PAST?
o DATE
DESCRIBE
GALLONS
❑ IS THERE ANY OTHER FLAMMABLE OR HAZARDOUS MATERIALS STORED ON -SITE?
00
0 YES LIST:
❑ NOTES:
EACH BOX MUST BE CHECKED BEFORE REMOVAL OF THE UST
❑ TANK PERMIT FORM # FP-292
❑ DIGSAFE # DATE OBTAINED DIGSAFE # 1-800-322-4844
❑ TANK INFORMATION: FIBERGLASS,
CYLINDRICAL TANK
D
-- L —�
Form
ula for a CYLINDRICAL TANK
( 2 x 2 x 3.1464 L
231iiilll = gallons
D = inches L = inches
STEEL
0 UST SIZE _ 00() GALLONS
0 O GALLONS OF OIL EMPTIED FROM TANK
0 Q GALLONS OF WATER EMPTIED
0 INCHES OF OIL IN TANK 0 INCHES OF WATER
❑ BACKFILL MATERIAL - GRAVEL LOAM SAND WILLPACK OTHER
❑ EXCAVATION (CIRCLE ALL THAT APPLY)
O LINED WITH POLY
O COVERED WITH POLY
0 FENCED IN WITH: SNOW FENCING CHAIN LINK FENCING CAUTION TAPE
❑ ## OF PHOTOGRAPHS TAKEN' PIPING TANK EXCAVATION
❑ ## OF DRUMS LEFT ON SITE: CONTENTS:
0 LOCATION OF DRUMS: KE (DRUMS CAN NOT BE LEFT ON GRASSY AREAS)
0 ## OF TOTES OR FRAC TAN CONTENTS:
❑ NOTES:
SITE SKETCH:
PLEASE INDICATE: 1. The location of the UST
2, The UST piping
3, Field screening points & laboratory sample collection
4.General observations
NOTES:
-3-
❑ IS THERRN�Y STRESSED VEGETATION OR DISCOLORED PLANTS IN THE AREA')
o N ✓✓
o YES DESCRIBE:
❑ IS THERE ANY BROKEN OR PATCHED PAVEMENT AROUND OR NEAR THE (CIRCLE IF YES)
TANK FILL PIPES PUMPING ISLANDS OTHER
❑ IS THERE ANY STAINING ON/AROUND/ABOVE THE (CIRLCE IF YES
TANK FILL/VENT PIPES LINE AREA OTHER
❑ FILL MATERIAL - GRA�tVELr NATIVE FILL OTHER
Cl DEPTH TO TOP OF TANK - ` { FEET
EACH BOX MUST BE CHECKED DURING THE REMOVAL OF THE UST
❑ FD PERSONNEL ON -SITE: NAME TITLE
❑ ON THE TANK IS THERE ANY VISIBLE SIGNS OF:
0 HOLES/BREAKAGE DESCRIBE f�r�
0 RUST/CORROSION DESCRIBE
O STAINS DESCRIBE
0 OTHER DESCRIBE
❑ IN THE EXCAVATION IS THERE ANY VISIBLE SIGNS OF:
0 SOIL STAINING DESCRIBE
0 OTHER DESCRIBE
❑ GROUNDWATER EVALUATION:
IS THERE GROUNDWATER IN THE EXCAVATION?
NO YES
IF YES IS THERE:
FREE PRODUCT DESCRIBE
SHEEN DESCRIBE
1 ADULA
DATE
(M/DD/YY)
1j
11
TIM
(0:00 AM
SAMPLE ID
SAMPLE
SIDEWALL 1
DEPTH
(FEET)
PID
(PPM)
PID BACKGROUND
(PPM)
SAMPLER
(INITIALS)
i
NOTES
I
W
SIDEWALL 2
SIDEW AI
0
0-
G
_
C'
SIDEWALL 4
PIT BOTTOM
a
O
C1
+
PIPIN
NOTES:
❑ AR THERE PETROLEUM ODORS IN:
O NEARBY STORM SEWERS — PID READING Ppm
DRAINAGE DITCHES - PID READING Ppm
/ O BASEMENTS - PID READING Ppm
Ik WETLANDS - PID READING Ppm
❑ HAS THE TANK BEEN CLEANED?
O DE
0 INSI