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!fi <br /> PUBLIC H-- -TH SERVICES—ENVIRONMENTAL( ALTH DIVISION <br /> SITE NAMES 5-f /J ADDRESS - I CITYbe' C' G <br /> i I cC�C <br /> OWNER NAME `U+ c-e. OWNER PHONE aAl <br /> # <br /> CONTRACTOR G CONT. PHONE <br /> FIRE PERMIT ` <br /> REMOVAL__Z.�- CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 39 <br /> R RINSED O/N) METHOD RINSE AMOUNTU <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S 3 <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ( N) METHOD <br /> :�eAMOUNT USED <br /> ; <br /> E P READING AT REMOVAL L.E_L_ : -'02: <br /> E O p� <br /> l` R COMMENTS <br /> C TANK MATERIAL (STEEL, ( IBERGLASS OTHER) OYt� Gd'`v1•L�n <br /> 0 <br /> N TANK CONDITION . GOO . POOR, HOLES} 7,,� <br /> f S it <br /> T PIP£ MATERIAL. (STEEL, FIBERGLASS, OTHER) ';FEET <br /> PIPE CONDITION GOOD POOR, HOLES} <br /> DEPTH SOIL TYPE OBSERVATIONSAMPLE <br /> A <br /> K I s" v <br /> !+ 4� <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P �. �' !;w '' ! <br /> L I r 7 S a`Gc�- <br /> I P i <br /> NE <br /> G ,.. f <br /> TRENCH DIlEENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. —[-SAMPLING METHOD <br /> CE DEWATERING , <br /> 2 Ji HOURS SIN - <br /> • <br /> 0 F <br /> F ! <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME:LL <br /> GGRS <br /> CLOSURE IN PLACE MIXTURE: i'� VOLUME: <br /> ""EH 23--0043 (REV 2/23/94) PROVIDE SITE MAP <br />