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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAMED G�J ADDRESS 6� i✓, �I CITY S � <br /> OWNER NAME C>G 6bac� . OWNER PHONE # 7 777- 33 7 <br /> CONTRACTO$Skd ScVL -CJ4- CONT. PHONE <br /> FIRE PERMIT ,# 7- 7 <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR W DATE �tU .11 TANX .4 39 <br /> R RINSED YIN) METHOD �i � RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S c <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED 6/N) (METHOD AMOUNT USED /U IDs <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL TE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET ro <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE ` <br /> T 17 / <br /> N — s <br /> K <br /> S EXCAVATION SIZE X _ X 6 � YDS OF SOIL 7 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: rck. 6�- <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />