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YUISLIC: rit;AL'lH SERVICES—ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS S CITY <br /> OWNER NAM OWNER PHONE j <br /> CONTRACTOR CONT. PHONE <br /> 2 - <br /> FIRE PERMIT ¢ <br /> REMOVAL�� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATEg TANK # 39 <br /> R RINSED MN) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED(7t�p) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 8 9D 02 : /p <br /> 0 <br /> R COMMENTS 4,, <br /> C TANK MATERS (STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD OOR HOLES) <br /> S <br /> T PIPE MATERI TEFL, IBERGLASS, OTHER)T# FEET ' <br /> PIPE CONDITION (GOOD, )' HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T —1 I <br /> AFT )� <br /> N <br /> K S <br /> S EXCAVATION SIZE �' C l�j X � YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P F <br /> L I n o� E% r <br /> I P <br /> N E G <br /> G <br /> TRENCH DIMENSION Z X X 2 r(�}) 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 I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />