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PUBLIC HE" 7H SERVICES-ENVIRONMENTAL �'ALTH DIVISION <br /> SITE NAMEDRD CcG �j v ADDRESSI��� � K���� CITY\S6 / L <br /> OWNER NAME ?) OWNER PHONE # <br /> CONTRACTOR 5'� �C C) CONT. PHONE # <br /> FIRE PERMIT # 1`J 3C�J d-LIrnSI/G T) nS pec fOl� CID 5 <br /> 'aj <br /> REMOVAL CLOSURE IN PLACE T64PORARY CLOSURE <br /> INSPECTOR - j� - DATE .3' �t J TANK # 3 9 —L-6, If Lf <br /> R RINSED Y N) METHOD RINSE AMOUNT -- <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED FY METHOD AMOUNT USED3SI <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 w <br /> R COMMENTS <br /> C TANK MATERIAL TE FIBERGLASS, OTHER) <br /> 0 ;t <br /> ted <br /> TANK CONDITION (GOOD, OOR HOLES) �n G ;tted <br /> S <br /> T PIPE MATERIALSTEEL,; FIBERGLASS, OTHER) # FEET w - � f �� <br /> PIPE CONDITION (GOOD, POOR, HOLES) Z�.�fGrG r Sdt,cyhu�i <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> Hi 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: Coo SAMPLERS NAME: T, , u6( <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />