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PUBLIC HEAL'1'ZERVICES-ENVIRONMENTAL HEAul' H DIVISION <br /> SITE NAME d 4r ADDRESS 3133 A). 14cl&,a Rd, CITY .Sf��,/C• v� <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR Adv G o CONT. PHONE <br /> FIRE PERMIT # il IVe <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE W-,)6 Cl TANK # 39 Ce <br /> R RINSED (9N) I METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD ) G� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 5L 02: (� <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL TE ', FIBERGLASS, OTHER) <br /> 0 ,p�{ <br /> N TANK CONDITION (GOOD, OR, HOLES) <br /> S <br /> T PIPE MATERIALSTEEL FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) �� r <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A hu, 3 <br /> K haC <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I S <br /> I P <br /> N E <br /> G <br /> SO- <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: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVS)E SITE MAP <br />