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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS J3-,,-AG�j�E CITY S�bc �o <br /> OWNER NAME I OWNER PHONE # Coos Sys_ 3sq <br /> CONTRACTOR-yjyy,,�_5 K I CONT. PHONE 779 Tj <br /> FIRE PERMIT <br /> REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR` DATE 9/yr 9� TANK # 39 /007 <br /> R RINSED CY.PN) Y-ETHOD /PGS 2 NSF RINSE AMOUNT G/ <br /> I <br /> N RINSATE DISPOSAL SITE �J ✓i Po/�� <br /> U c'� <br /> S <br /> E MANIFEST Z OR OTHER <br /> V VAPORS PURGED -&� ) METHOD PAY TGE AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL ST FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD POO HOLES) �S <br /> S <br /> T PIPE MATERIAL ( , OTHER) # FEET <br /> PIPE CONDITION (GOO, n—SOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> M sort.. vl_511' <br /> N ^ r 5 cAy 47 Sc�6 v Drax t cc rx>vr <br /> K <br /> S EXCAVATION SIZE^L X^f-7— X-� IZ YDS OF SOIL - ��07y-pC <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: <br /> CLOSURE IN PLACE HIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />