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PUBLIC HEALIrE SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME U5 (ADDRESS (' CITYS <br /> OWNER NAME I OWNER PHONE <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERlvaT <br /> REMOVAL_ CLOSURE :N PLACE TEMPORARY CLOSURE <br /> INSPECTOR �Q�Lrm- DATE , TANK ;rl 3 9 I rjjrj 6 <br /> R RINSED (Ye I METHOD RINSE AMOUNT <br /> 1 <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED �) (METHOD (AMOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : 1173 I 02: <br /> 0 <br /> R COMI=S-- � <br /> C TANK MATERIAL (STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, ;OOR)HOLES) <br /> S <br /> T PIPE MATERIA (STE , FIBERGLASS, OTHER) I � FEET <br /> PIPE CONDITION (GOOD _OOR, OLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE r <br /> m <br /> A 12.S N 5' s <br /> e� <br /> N �- <br /> K I I <br /> S EXCAVATION SIZE ,��Y �)X - D YDS OF SOIL l <br /> A <br /> M DEP'T'H ( SOIL TYPE OBSERVATION ( SAMPLE 7-0 <br /> P P I i <br /> L I <br /> I P I I I <br /> N E <br /> G <br /> TRENCH DI=SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING (ME'T'HOD <br /> H <br /> 2 rl HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: -T SAMPLERS NAME: j <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />