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PUBLIC HEAL�ri SERVICES-ENVIRONMENTAL HMLTH DIVISION <br /> SITE NAME r. (,:�. S 0 ,7 ADDRESS �e���St CITY )1fi(�CTOr� <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR CONT. PHONE b 7-71 <br /> _ S <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 7`d DATE /p g TANK # 39 �Q J,` 2 <br /> R INSED (Y/N� METHOD r RINSE AMOUNT <br /> N INSATE DISPOSAL SITE PA - 4u„Q Gti 1,pati � e ,�,_Sw &4,,,,� <br /> S Gew 67 g7" <br /> E MANIFEST # OLZ�SZ OR OTHER �v33O <br /> VVAPORS PURGED ()N) METHOD AMOUNT USED <br /> A <br /> P EADING AT REMOVAL L.E.L. 02 : <br /> 0 , <br /> RCOMMENTS '3'7 0 c �� <br /> C ANK MATERIAL � E , , FIBERGLASS, OTHER) <br /> 0 <br /> N ANK CONDITION (GOOD, POOR, HOLES) , �^ r p L <br /> S <br /> T IPE MATERIAL (STEEL, FIBERGLAS ,'6THER)/,M # FEET �ON' <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A < . 4,,,6 s`-- w <br /> N <br /> K <br /> S XCAVATION SIZE _' X X YDS OF SOIL <br /> A 11 <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P N <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : : 36 FT. SAMPLING METHOD N� , <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: S ��� SAMPLERS NAME: <br /> CLOSURE IN PLACE MATURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />