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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS <br />CITY CITY S'77eze7-0 <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTOR-TA,y,,�5 � <br />CONT_ PHONE q4�7- -7795 <br />FIRE PERMIT <br />REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR,4 DATE 9�yr 9� TANK # 39 loo -7 o <br />R RINSED O./N) HETHOD��,?ck�,¢ �c�c RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE�,,e cvF <br />S <br />E <br />MANIFEST OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED (VN) METHOD � � AMOUNT USED <br />READING AT REMOVAL L.E.L.: Z �� 02: <br />COMMENTS <br />C <br />TANK MATERIAL" T�„=-FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, OOR; HOLES) <br />S <br />T <br />PIPE MATERIAL CITE, OTHER) <br /># FEET 3�Rr5E� <br />PIPE CONDITION (GOOD�3-06k;:::lHOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />^ 8 /q6oOoR o sei� 'TA L' +� <br />A <br />N <br />K <br />S <br />EXCAVATION SIZE ^ 6 X 2 X S <br />YDS OF SOIL 6 <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />AA I <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: �� <br />SAMPLERS NAME: vrG,e�E <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />