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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME �, <br />ADDRESS J�� AG�y� .ve <br />CITY STp�,l�r-o <br />OWNER NAME k <br />OWNER PHONE # �cfo8 3`7J�- 349 <br />CONTRACTOR-yA,y,,�,5 r�T�e1 <br />CONT. PHONE # (45�� -779Tj <br />FZRE PERMIT # <br />REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR v DATE TANK # 39 /00'7 o_ <br />R RINSEDN) METHOD��PG� RINSE AMOUNTx�,gJ <br />— <br />I <br />N <br />RINSATE DISPOSAL SITE f ✓i�oi�� <br />S <br />E <br />V <br />MANIFEST # OR OTHER <br />VAPORS PURGED -e N) METHOD Q�'Y AMOUNT USED e����� <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />02: <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL ST ' FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD POO HOLES)I <br />AL <br />S <br />T <br />PIPE MATERIAL ( OTHER) <br /># FEET <br />PIPE CONDITION (GOO9:y:�HOLES) <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />T <br />n 5iJ o/G� <br />o Dose o �,� visc�cae4-na �+�/r <br />A <br />/ 5 1.4Y vw) <br />a <br />N <br />K <br />S <br />EXCAVATION SIZE^Z5,ol X^fes_ X -,_/Z- <br />YDS OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />L <br />P <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />x <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: C d °r FiC <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />