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PUBLIC H"LTH SERVICES-ENVIRONMENTAL, HEALTH DIVISION <br /> SITE NAME �� ADDRESS / CITY <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT # 9� _ Zo <br /> REMOVAL__ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE Z/�f 9(0 'DANK # 39 `,05'7 '0V /-bl6d0 UL <br /> R RINSED N) I METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (� N) METHODS AMOUNT USED Z)20"- <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> O /^� 1 <br /> R COMMENTS ��� �'"`� �ju�j-Pp ��2.�i� �p r/y6 4aa-�z <br /> C TANK MATERIAL (STEEL FIBERGLASS, OTHER) ( o <br /> 0 <br /> N TANK CONDITION GOODPOOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS OTHER) # FEET 3O <br /> PIPE CONDITION (GOOD, POOR, HOLES) Y-i 67�) C <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T _ T E 22' <br /> A _ � . <br /> NRµLao. O <br /> K Aft4E5 <br /> 141 L-0-7- <br /> S EXCAVATION SIZE 3S X X -1= YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P Ale Q _�u<aCn- i <br /> L I <br /> I P o�l <br /> N E <br /> G v+ <br /> TRENCH DIMENSION X X O YDS OF SOIL <br /> DEPTH TO G.W. : F3 y 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 />