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PUBLIC .ALTH SERVICES-ENVIRONMENT HEALTH DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME ` OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # �. <br /> FIRE PERMIT # qG' <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR <br /> TANK # 39 <br /> R RINSED,1 41 N) METHODS . <br /> RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # _ OR OTHER <br /> V VAPORS PURGED (YIN) METHOD » AMOUNT USED /5i7 <br /> E G� <br /> U0R <br /> READING AT REMOVAL L.E.L. : O2 ; <br /> COMMENTS <br /> F <br /> TANK MATERIAL (STEEL, FIBERGLASS', OTHER) <br /> N TANK CONDITION (GOOD�OOR,j HOLES) <br /> S --- <br /> T PIPE MATERIAL (STE , FIBERGLAS8-, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A <br /> N <br /> K <br /> SEXCAVATION SIZE X^ '' X ^rZ. 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 /> 17 DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> G��3c. <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />