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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME 5 L ADDRESS S CITY <br /> OWNER NAME S�G OWNER PHONE Cl <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT / <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED YON) METHOD - ' W.�a RINSE AMOUNT �S4 <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # 6 S94Cih OR OTHER <br /> V VAPORS PURGED MN) METHOD AMOUNT USED 2.4 <br /> A <br /> P READING AT REMOVAL L.E.L. : c 02 : cl �C <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASSOTHER) 2 5/E�1 <br /> O <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAL (STE , FIBERGLASS, 0 ER) FEET �7 <br /> PIPE CONDITION (GOOD, 00 S) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE i <br /> T <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 /> UL 11 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 />