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PUBLIC � SERVICES-ENVIRONM3NTA,.,6.ALTH DIVISION <br /> SITE NAME <br /> ADDRESS .T CITY <br /> OWNER NAME San Soaqu h OWNER PHONE if <br /> Uq� 4(08 -325 <br /> CONTRACTOR (�Gr G ©t ( CONT. PHONE # <br /> FIRE PERMIT A%000q <br /> REMOVAL CLOSURE IN PLACE TE'12ORARY CLOSURE <br /> INSPECTOR YpS4lio�ScL DATE z-/(o_910 TANK $ 39 1 3 <br /> L; r <br /> R RINSED (CyN) METHOD <br /> I RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> VV VAPORS PURGED ©/N) (METHOD �I (CC- AMOUNT USED <br /> (be <br /> P READING AT REMOVAL L.E.L. : </o S 02 : 2 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POO , HOLES) <br /> S <br /> T PIPE MATERIAL ( TEEL FIBERGLASS, OTHER) .4 FEET 0 <br /> PIPE CONDITION (GOOD, 00 , HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION <br /> T SAMP?E s <br /> A <br /> N Ye ' CI <br /> K 8 <br /> S EXCAVATION SIZE I Z X 1 X �iy <br /> A YDS OF SOIL <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I ruh oven rtla <br /> I P OVA uv <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> H DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: I SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />