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PUBLIC HEALTH SERVICES -ENVIRONMENTAL REALTH DIVISION <br />SITE NAME `.. <br />ADDRESS J <br />CITY S��o <br />OWNER NAME <br />OWNER PHONE # (cfp8 1 3�js- 34q <br />CONTRACTORrTA,5,4�5 1�rT CL <br />CONT. PHONE # (Zoyl 44!5 _ 779 <br />FIRE PERMIT # <br />REMOVAL x CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE 9/yr 9 TANK # 39 /oafall <br />R RINSED (Y?N) METHODRINSE AMOUNTSca,e,/ <br />I <br />N <br />RINSATE DISPOSAL SITE Enl vi/Q,ft 2. Cti�gT <br />S <br />E <br />V <br />MANIFEST #s `�'�6"��9Z OR OTHER <br />VAPORS PURGED ) METHOD AMOUNT USED 65b /b5 <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: 0 6 <br />02: <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL TE 7 FIBERGLASS, OTHER) <br />0 <br />N <br />_ <br />TANK CONDITION (GOOD, 00 OLES) <br />(� K CAs <br />S <br />T <br />_ <br />PIPE MATERIAL F T STC OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, 00 OLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />^ /6 5!J '�/52'T mor OrScoGod4•Tex o�b� TA L' d L <br />A <br />^/J���7 9GrL`T r Or9. GD.�j�o G9:b ri L� 1Z Sovr <br />N <br />K <br />S <br />EXCAVATION SIZE ^ 75_`f ^ X ^ X ^ r 2 <br />YDS OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />L <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 />H <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: rr'/lEG/ <br />SAMPLERS NAME: Lr� <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />