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PUBLIC HEAX2T117H SERVICES—ENVIRONMENTAL hr_ALTH DIVISION <br /> SITE NAME // V ADDRESS ��^ G DG�f CITY GcsO� <br /> OWNER NAME OWNER PHONE # ?68_ 7/t/� <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE/t-/f7/9_6 TANK # 39 <br /> RRINSED (3'i/N) METHOD CL !I RINSE AMOUNT <br /> I l <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (I)N) METHOD � , � AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : ,� 02 : g <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, OOR HOLES) <br /> S <br /> T PIPE MATERIAL (5TH_ , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A <br /> K <br /> S EXCAVATION SIZE X 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 Ll <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: bL hU SAMPLERS NAME: <br /> CLOSURE IN PLACE 7MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />