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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS 535 C' <br />CITY <br />OWNER NAME <br />OWNER PHONE ZOs� <br />CONTRACTOR <br />CONT. PHONE <br />FIRE PERMIT # D39 <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR, <br />DATE < TANK # 39% OO'Q5- 7.SK6<is <br />R <br />I <br />N <br />S <br />E <br />RINSED Y/ ) METHODt RINSE AMOUNTS ADO <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED Y N) <br />READING AT REMOVAL <br />COMMENTS <br />METHOD / AMOUNT USED �5 <br />�^ <br />L.E.L.: /5 02: /.0 <br />C <br />O <br />TANK MATERI (STEEL, <br />IBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOOD) <br />POOR, HOLES) <br />T <br />PIPE MATERIAL STE <br />FIBERGLASS, OTHER) # FEET <br />PIPE CONDITION (GOOD, <br />POOR) HOLES) <br />T <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />A <br />N <br />Z <br />f <br />K <br />S <br />A <br />EXCAVATION SIZE X 6-0X <br />YDS OF SOIL ,Q�®( <br />M <br />P <br />P <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />L <br />I <br />I <br />Ps. <br />P <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION <br />I -S X 2•o X <br />YDS OF SOIL <br />DEPTH TO G.W.• <br />GU FT. <br />SAMPLING METHOD <br />H <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />