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PUBLIC HEALTH SERVICES—ENVIRONMENTAL HE%LTH DIVISION <br /> SITE NAME-)0i. ADDRESS <br /> OWNER NAMEOWNER PHONE f <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT <br /> L G <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �,�, ��, DATES'$ I " il-�f TANK 1 39 _LA2 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> VVAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P EADING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R OMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> nth DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> bt TA c _ <br /> N <br /> K <br /> fr I o im , C1o�i <br /> S EXCAVATION SIZE X X YDS OF SOIL � <br /> V <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I `U <br /> i <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : 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 />