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PUBLIC HEA:,TH SERVICES-ENVIRONMENTAL H1;ALTki UlV1S1VN <br /> SITE NAME5-JC <br /> IE� AQgM+ CITY lIng <br /> OWNER NAME S OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR-0DATE TANK if 39 11719 1p— <br /> METHOD ltil RINSE AMOUNT <br /> R RINSED YON) <br /> I <br /> NRINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # QLois n a 6 a OR OTHER <br /> V VAPORS PURGED C N) METHOD AMOUNT USED L 0 <br /> A <br /> P READING AT REMOVAL L.E.L. : d c 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS OTHER Z <br /> 0 <br /> N TANK CONDITION (GOOD, COR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS OTHER) # FEET <br /> PIPE CONDITION (GOOD,<1 OOR, OLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A # <br /> T C 1 2 I <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <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) PROVIDE SITE MAP <br />