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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAM51 <br />ADDRESS <br />CITY <br />OWNER NAME a ze �-�- <br />OWNER PHONE <br />CONTRACTOR �tGE <br />CONT. PHONE <br /># <br />sd �Z6•/ <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE <br />TEMPORARYCLOSURE <br />INSPECTOR `�.J1 <br />DATE TANK <br /># 39 F00 X06ZK � ul- <br />R <br />I <br />N <br />S <br />E <br />RINSED (Y)N) METHOD <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR <br />OTHER <br />RINSE AMOUNT <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED (9N) <br />READING AT REMOVAL <br />COMMENTS <br />METHOD <br />L.E.L.: GJ % <br />AMOUNT USED 504* <br />02: Z. <br />C <br />0 <br />TANK MATERIAL ( TE , <br />FIBERGLASS, <br />OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, <br />POOR, <br />T <br />PIPE MATERIAL @EELD <br />FIBERGLASS, <br />OTHER) <br /># <br />FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />T <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE # <br />A <br />N <br />K <br />S <br />A <br />EXCAVATION SIZE X X <br />�_ <br />YDS <br />OF SOIL �v 3 <br />M <br />P <br />P <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE # <br />L <br />I <br />I <br />N <br />P <br />E <br />G <br />TRENCH DIMENSION <br />X <br />X <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />GCD FT. <br />SAMPLING METHOD <br />H <br />2 <br />0 <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />