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PUBLIC HEALTH <br />HEALTH DIVISION <br />M. DDRESS <br />SITE NAM n 2h 5. S }oma <br />OWNER N a J l l� OWNER PHONE # S$- y Z 6 <br />CONTRACTOR svvtc iD CONT. PHONE # S Z �/ - %G S <br />FIRE PERMIT # y orl <br />REMOVAL ✓ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE � _j6_ct TANK # 39 lyct�N <br />R RINSED wN) 5-e-- RINSE AMOUNT 3z� <br />N <br />RINSATE DISPOSAL SITE 14 )h <br />SOR <br />E <br />MANIFEST # OTHER <br />V <br />VAPORS PURGED ) <br />METHOD Ck ��� <br />AMOUNT USED <br />Aj, <br />P <br />READING AT REMOVAL <br />L.E.L.: Q � <br />o <br />02: i � <br />0 <br />R <br />COMMENTS <br />TANK MATERIAL (STEEL, FIBERGLASS, OTHER) /o ooj Ilcbcl <br />C <br />0 <br />N <br />TANK CONDITIO (GOOD POOR, HOLES) <br />S6 <br />T <br />PIPE MATERIAL ST , FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION OOD OOR, HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />A <br />N <br />K <br />S <br />EXCAVATION SIZE X / z X <br />YDS OF SOIL <br />ASAMPLE <br />M <br />DEPTH SOIL TYPE OBSERVATION # <br />P <br />P <br />L <br />I <br />I <br />P <br />N <br />E <br />GX <br />TRENCH DIMENSION � X <br />YDS OF SOIL <br />H <br />2 <br />DEPTH TO G.W.: —`FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: �- <br />LABORATORY: Co �nG T �4/ <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />