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SITE NAME <br />OWNER N <br />CONTRACTORI <br />FIRE PERMIT I <br />PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />� <br />J&DDREss <br />/ ' I CITY � /�' �,(� r 1�^..� <br />. I OWNER PHONE <br />CONT. PHONE ✓tel I J - <br />? j" <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE 1L (-' � f TANK t 39Z— <br />R RINSED (Y/N) METHOD RINSE AMOUNT <br />I <br />N RINSATE DISPOSAL SITE (L-ZT <br />S <br />E MANIFEST OR <br />V VAPORS PURGED ( /N) METHOD <br />A Q <br />P READING AT REMOVAL L.E.L.: <br />0 <br />R COM. =1 1S <br />C TANK MATERLAL STEEL <br />0 <br />N T_7UTK CONDITION ( GOOD <br />S <br />Ir PIPE MATERLaL (STEEL, <br />PIPE CONDITION (GOOD, POOR, HO <br />DEPTH (SOIL TYPE (OBSERVATION <br />I N <br />A <br />P <br />L <br />I <br />N <br />G <br />(AMOUNT USED <br />02: ,_S <br />FIBERGLASS, OTS) <br />POOR S) <br />FIBERGIS , OTHER) I,% FEET <br />EXCAVATION SIZE 6, X I (' x �) <br />DEPTH SOIL TYPE IOBSE+RVATION <br />P <br />T <br />P <br />2 <br />0 <br />YDS OF SOIL <br />SAMPLE T <br />r <br />■FAri�dFA <br />�I I <br />IULIIKVI <br />�z -J2 <br />-3> <br />TRENCH D SIGN X <br />X YDS OF <br />SOIL <br />DEPTH TO G.W.: <br />=FT. <br />(SAMPLING METHOD 6 <br />o <br />HOURS SINCE <br />DEIRTATERING: <br />OTHER SAMPLE: <br />i <br />j <br />LABORATORY: ( SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: ( VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />