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PUBLIC HbTH SERVICES-ENVIRONMENTAL i� ALTH DIVISION <br /> SITE NAME /�2n �3 ADDRESS �D3y 5, L CITY <br /> OWNER NAMEv� u OWNER PHONE s l D - Z�� ' �3/51 <br /> CONTRACTORAlvqtl� <br /> CONT. PHONE <br /> FIRE PERMIT N&f <br /> REMOVAL CLOS IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE /(-Zla- q& TANK # 39 4LC40 pD2 <br /> R RINSED Y ) METHOD RINSE AMOUNT �jOs <br /> I <br /> N RINSATE DISPOSAL SITE e G�Z`2 ✓!�_ %l "� <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED Y)N) METHOD p AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : <-/p%b 02 : z <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR,(Ho 1 3 <br /> S <br /> T PIPE MATERIAL TEEL, FIBERGLASS, OTHER) # FEET = gyp` <br /> PIPE CONDITION (GOOD, POOR, 22S <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE a <br /> Tn,e tr iu© a <br /> A <br /> N o <br /> K T <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SJ61PLE <br /> P P „ L <br /> L I <br /> I P _ <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. :__L'�) FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <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 />