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PUBLIC HEAI SERVICES-ENVIRONMENTAL H jTH DIVISION <br /> SITE NAME SOS 3 ADDRESS ZS �` CITY <br /> SITE <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR Gi __i„� CONT. PHONE # <br /> FIRE PERMIT # OZ�*6 <br /> REMOVAL ✓ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 4&4, <br /> DATE TANK # 39 /D 3 7 <br /> RRINSED ) METHOD L RINSE AMOUNT 55 <br /> LEN <br /> RINSATE DISPOSAL SITE <br /> MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y)N) METHOD �� AMOUNT USED Zp Z3 ' <br /> A <br /> P READING AT REMOVAL L.E.L. : �D 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERI (STEEL) FIBERGLASS, OTHER) <br /> 0 / J <br /> N TANK CONDITION (GOO OOR, HOLES) �aLP <br /> S <br /> T PIPE MATERIAL STEEL FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION GOOD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T -70 <br /> baa(" w <br /> A �Ip Soic �5 <br /> N elei� <br /> K o <br /> dlen <br /> S EXCAVATION SIZE 5 X g X -34YDS OF SOIL I-jp 616 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> TNL---Jl <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : (oCt FT. SAMPLING METHOD <br /> # HOURS SINCE DEWATERING: <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />