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300 GJ <br /> PUBLIL�,..EALTH SERVICES-ENVIRONMEN_�, HEALTH DIVISION <br /> SITE NAME1,,i 3t., ADDRESS l3ZS- A( (11-mf (0((OLL) CITY <br /> OWNER NAME ( OWNER PHONE # <br /> CONTRACTOR -TDjo,-pe, U I CONT. PHONE 94oS_ 61-45- <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TE'4P0RARY CLOSURE <br /> INSPECTOR DATE D TANK .4 39 /3ZJ C <br /> R RINSED (2?yN) METHOD RINSE AMOIINT <br /> I <br /> N RINSATE DISPOSAL SITE N O0 ecz,I <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED &N) METHOD r� +�� AMOUNT USED of <br /> A <br /> P READING AT REMOVAL L.E.L. : Q 02 : C, <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL OCTEt6, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OO , HOLES) ko <br /> S <br /> T PIPE MATERIAL kgEL FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> .Tdw <br /> n /< ' <br /> A <br /> N <br /> R <br /> S EXCAVATION SIZE _ X X YDS OF SOIL <br /> A <br /> M DEPTH I SOIL TYPE OBSERVATION SAMPLE r <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIl'g.11SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> x <br /> 2 if HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: I SAMPLERS NAfE: <br /> CLOSURE IN PLACE MIXTURE: I VOLUME: <br /> 1 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />