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PUBLIC HEA—_fH SERVICES-ENVIRONMENTAL rro&LTH DIVISION <br /> SITE NAME /�-��L ADDRESS /�� GvXFL CITY Gua <br /> OWNER NAME v_ �vL OWNER PHONE <br /> CONTRACTOR "Ay ��� � - CONT. PHONE <br /> �. 8z6-off <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORrG DATE �Z�7 �6 TANK 39 <br /> R RINSED J1/N) METHOD RINSE AMOUNT iSGC <br /> I <br /> N RINSATE DISPOSAL SITE <br /> E MANIFEST l' , -r „ OR OTHER <br /> V VAPORS PURGED (Y/N) METHODAMOUNT USED cj c <br /> A <br /> P READING AT REMOVAL L.E.L. : % 02 : <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 — <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> ?- <br /> A - .•y- b/1%L: o sa< .1scx✓a'+%�... z- /- <br /> N <br /> K <br /> S EXCAVATION SIZE '.' X =` X �(Z' 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 /> 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: SAMPLERS NAME: <br /> CLOSURE IN PLACE 7MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />