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PUBLIC HEP T•TH SERVICES—ENVIRONMENTAL FIXLTH DIVISION <br />SITE NAME <br />OWNER NAME / 1i ` OWNER PHONE <br />CONTP_ACTOR_p,A I CONT. PHONE <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK 39 <br />R RINSED (�N) ;D✓ 00 RINSE AMOUNT <br />I <br />N RINSATE DISPOSAL SITE <br />S <br />E MANIFEST OR OTHER <br />V VAPORS PURGED /N) METHOD Df�p AMOUNT USED <br />A <br />P READING AT REMOVAL L.E.L.: �� 02: <br />r <br />0 <br />R COIM1�=S <br />C T-XNK MATERI.A.L (STEEL, FIBERGLASS, OTHER) <br />0 <br />N TANK CONDITION (GOOD, 00 HOLES) <br />S <br />T PIPE MAT IAL (. FIBERGLAS , OTH�r-R) I FEET <br />PIPE CONDITION (GOOD,PO0 HOLES) <br />DEPTH I SOIL TYPE (OBSERVATION ISAMPLE <br />S <br />A <br />M <br />p <br />L <br />I <br />N <br />G <br />T <br />A <br />NK <br />P <br />T <br />P <br />E <br />H <br />2 <br />0 <br />L <br />EXCAVATION SIZE L X _SL X (YDS OF SOIL <br />DEPTH ISOIL TYPE IOBSERVATION (SAMPLE <br />T' I 1 I />r<'s t, <br />TRENCH DIMENSION_ X <br />X <br />YDS OF SOIL <br />DEPTH TO G.W.:��� FT. <br />(SAMPLING <br />METHOD <br />24 HOURS SINCE DEWATERING: <br />-- <br />OTHER SAMPLE: <br />JI LABORATORY: I SAMPLERS NAME: <br />CLOSURE IN PLACE MIX=: I VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />