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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS) ,- fE CITY .5,v, o <br /> OWNER NAME hA�CEQ OWNER PHONE # �cfc8 1 3`75- 3`79 <br /> CONTRACTOR-_TAyr, r,5 CONT. PHONE # (Z,y� 4,;(T5 _ -779Tj <br /> FIRE PERMIT # �y/�jr � l• f�� (7� rOG�o <br /> REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE 9,K/,r/ TANK # 39 loo-7 b <br /> RINSED ) METHOD RINSE AMOUNT �� <br /> IN <br /> RINSATE DISPOSAL SITE -jZ4&MANIFEST # OR OTHER <br /> V VAPORS PURGED (5:71I) METHOD 04-C t GG AMOUNT USED <br /> A �7 <br /> P READING AT REMOVAL L.E.L. : �� 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) 15;e cl <br /> S <br /> T PIPE MATERIAL S EEL BERGLASS OTHER) # FEET <br /> PIPE CONDITION (GOOD, OR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A / 5A� G SGr , caoa'scr �rG r roc �Prro / L- w 3 cr�r <br /> N (fj� 5cr.17P kr o d3 Sov <br /> K <br /> S EXCAVATION SIZE X ^ rzYDS 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:��e/�.��� SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />