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PUBLIC HEALTH ERVICES-ENVIRONMENTALWALTH DIVISION <br /> SITE NAME ADDRESS7S,,-i4G�3>�/E CITY Sit -o <br /> ^� <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR-Tfy 5 Ea CONT. PHONE # (2oy1 4c/5 _ 779 <br /> FIRE PERMIT # <br /> REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR '0�qry DATE 9r y TANK # 39 /00'7 <br /> R RINSED '<YjiI) METHODRINSE AMOUNTSm� <br /> I <br /> N RINSATE DISPOSAL SITE c' Ivr��L2 u�gT- <br /> S <br /> E MANIFEST # ��''�`�v ��64`1�L OR OTHER <br /> V VAPORS PURGED --tj�r-V) METHOD A AMOUNT USED 65o I�5 <br /> A Ir <br /> P READING AT REMOVAL L.E.L. : 0 6 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, 00 OLES) <br /> S <br /> T PIPE MATERIALB R— GLS OTHER) # FEET <br /> PIPE CONDITION (GOOD, 00 OLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T ^/6 9/J d/52T <br /> C094 <br /> TA Ld LA oab� <br /> N I� 4e- d2- <br /> so' r <br /> K <br /> S EXCAVATION SIZE^i_`7 ' X -30- X ^r2- - YDS OF SOIL <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: GAG <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />