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PUBLIC HEALTH SERVICES—ENVIRONM/�E"N'TAL HEALTH DIVISION <br /> SITE NAME H. �Sc') � ADDRESS �'�`7 ( pLlh�ctccd ��. CITY,S��� � ` <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR �(1 �j r CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE] TANK # 39Q Qu (� _ <br /> R RINSED _jN) METHOD RINSE AMOUNT <br /> I <br /> N R—TNSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> 62 <br /> ER <br /> Y VAPORS PDRGID N) (METHOD AMOUNT USID — <br /> READING AT REMOVAL L.E.L. : 02 : <br /> COMMENTS <br /> C TANK MATERIALSTEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION GOOD' POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> I JI PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH ( SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T <br /> A <br /> N S. <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ISOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I < 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: C p ��t f71G I SAMPLERS NAME: ScC�rp2L. <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />