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PUBLIC �. <br /> SzR" VICES-�-lONh!XTALJ&H DIVISION <br /> SITE NM vs. t`� ADDRESS CITY 1 <br /> ow-rr...R NAMr L)S. 1-s� °� PHONE (Zo <br /> CONTRACTOR CNT. PHONE <br /> (q1 .3:j� Z - ���5 <br /> FIRE PST <br /> R <br /> -R-in-To VA�j i CLOSURE SPT .. — TL..A' i 0RARY CLOSGRE <br /> INSPECTOR rn _ DATE <br /> R R.�iSED �'N) ?'HO❑ j��'�L� it <br /> RINSE AMouyv <br /> T l2 � � <br /> � r`t�T�i'SATE DISPOSAL SITE �P��^M1OS C Vi R�?V+'►1GN�'L f <br /> Z MNYITZST s 99 '43 43 T.3ZZ OR OTHER ak f I <br /> i <br /> V 7WORS PURGED QN) _"ITEOD 13� �G !AMOUNT USED <br /> A E `JO <br /> P RE'.AD_TVG Am R. -VY-OVAL L.E.L. : <br /> C ' T1176 MATERIAL (STEZL, O'I'L'" ) I <br /> 0 <br /> N 1110 CONDI'T'ION (GOOD, OOR, EO <br /> T _PZ2E MATERIAL (STMZ;, "IBERASS,GLOM-=) I �' =EET <br /> t <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> Ir w <br /> DEPTH SOI,:..: 17?E J OBSERVATION ' � I SAMPLE T j <br /> T, <br /> I� 9.1 <br /> Y I <br /> � I I <br /> S I EXCAVATION SiZF. X $ X YDS� OF SO! Z� <br /> I� DE= ISOIL =E I OBSERVATIONS ., I SAMPLE T <br /> L T I a S I <br /> I p f <br /> N E I I •" " I <br /> E G ! I I <br /> TRENCH DIMENSION X X i' YDS OF SOIL <br /> DOTH TO G_A. : FT. SAMPLING ME'T'HOD <br /> 2 s HOURS S ZNC E DEIrAMERINS: <br /> 0 k <br /> OTH_,.. SAMPLE: <br /> LABORATORY: ,}CC.ULA-&S SAMPLERS NAME:l y � <br /> I�C.T�D S u r E IN PLACE MIXTURE: VOLUME: I <br /> ZH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />