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PUBLIC HEP ''H SERVICES-ENVIRONMENTAL H' LTH DIVISION <br /> SITE NAME/;', t � F�pTo JADDRESS .:1`/� / "� Vii: r�� CITY � C1 C'6 r' <br /> OWNER NAME `OWNER PHONE # a�� � 6-A —3 Cr> a <br /> CONTRACTO `R r )l (CONT. PHONE # <br /> FIRE PERMIT # _l/I/ I �'(c' <br /> REMOVAL 7 CLOSURE LI PLACE TEMPORARY CLOSURE <br /> INSPECTOR L.Tt 41 r S DATE f C + _ TANK # 39 <br /> R RINSED (Y ) mETH D Gamrra-C-to-" RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/R-)') po64� /`A/rJ re94i-j.-cAM UNT SED �— <br /> A <br /> P READING AT REMOVAL L.E.L. : <br /> O <br /> R COMMENTS. L � , (��c w� , � SCS- 1 c � r E /v <br /> C TANK MATERIALB `E FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S I'S r ' �-_1 <br /> T PIPE MATERIALSTEEL )FIBERGLASS, OTHER) # FAT <br /> PIPE CONDITION (GOOD, 'POOR, OLES) No /(:-,,s,,, <br /> DEPTH SOIL TYPE IOBS ERV TION SAMPLE # <br /> T <br /> N P ` .z_ e _r Cry <br /> S EXCAVATION SIZE L X y_ X _LL_ YDS OF SOIL <br /> A - <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P - <br /> L I <br /> N E <br /> G <br /> TRENCH DIMENSICNj ISI X X YDS OF SOIL ,,b; �Q <br /> DEPTH TO G.W. : `} FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DL�ATERING: <br /> 0 - 4,5 F <br /> OTHER SAMPLG K ,y <br /> LABORATORY: (;'�d r,n),q L y'7 i<�:,¢/- SAMPLERS NAME: <br /> CLOSURE IN PLACE IXTUR.E: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />