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PUBLIC HEAImTl SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME b,,,,'e X '- ADDRESS ?Z S� s ��LQ CITY 6GG. <br /> OWNER NAME S IA OWNER PHONE <br /> CONTRACTOR ��� c7i CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR a eQ2 DATE Z' l 6 y TANK # 39 (Qy 33L <br /> FRI RINSED Y N) METHOD 1,-vRINSE AMOUNTIZ <br /> I <br /> N RINSATE DISPOSAL SITE 6q?67 gjac , <br /> S l U1�2 <br /> E MANIFEST # OR OTHER`1 Z$ <br /> V VAPORS PURGED Y N) METHODC U Y �j AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : F 02 : <br /> L <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL `TEE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOO , POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STi , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (!00:0, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T V 71 <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X _� X __7— YDS OF SOIL N <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P Al <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : �at FT. SAMPLING METHOD A"l - <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY:K012 — <br /> QSAMPLERS NAME <br /> CLOSURE IN PLACE MIXT VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />