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PUBLIC HEALTH Sr"F. tVICES-r" =ONMENTAL HEALTH DIVISION <br />SITE NAME(,d_ �' - <br />DRESS c l zv - <br />CITY <br />OWNER NAME�, <br />OWNER PHONE j16j <br />CONTRACTOR <br />I CONT. PHONE <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE �� �, ' TANK 39 G, Q <br />R <br />RINSED (Y/N) METHOD RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE 11 - <br />LS <br />S <br />E <br />MANIFEST r OR OTHER <br />V <br />VAPORS PURGED (Y/N) <br />METHOD AMOUNT USED <br />I DN <br />A <br />P <br />READING AT REMOVAL -T <br />L.E.L.: i3 102: <br />O <br />R -- <br />COMMENT <br />C <br />TANK MATERIAL ((TE , FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, POO -wuS ) <br />S <br />T <br />PIPE MATERIAL (STEEL, BERG , OTHER) I FEET <br />i <br />PIPE CONDITION (GOOD, .OO HOLES) <br />S <br />T <br />A <br />DEPTH (SOIL TYPE (OBSERVATION (SAMPLE <br />( �? ° /! U <br />EXCAVATION SIZE X s X <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />PL <br />I <br />p <br />E <br />DEPTH SOIL TYPE IOBSEaRVATION (SAMPLE <br />- S't - i <br />' <br />I <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />H <br />2 1 <br />0 <br />DEPTH TO G.W.: Z� FT. SAMPLING METHOD T9 <br />34 HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PNCE MIXTURE: ! VOLUME: <br />E.H 23-4043 (REV 2/23/94) PROVIDE SITE MAP <br />