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PUBLIC HZN' H SERVICES-ENVIRONMENTAL LTH DIVISION <br /> SITE NAMEGtS, f� ADDRESS - ` ` I CITYS L <br /> OWNER NAME / 0 7T_ OWNER PHONE # <br /> CONTRACTOR G N CONT. PHONE # <br /> FIRE PERMIT #` <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED , /N) METHOD Cl RINSE AMOUNT 3b 6 <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ( N) METHOD , AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : g 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, ZBERGLASS OTHER) ✓� C 'd�/Z��n c <br /> 0 <br /> N TANK CONDITION , GOO POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS,, OTHER) ,� FEET <br /> PIPE CONDITIONGOOD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION ( SAMPLE <br /> T <br /> A <br /> N u rcel <br /> K � bt <br /> S liEXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P 2 . � I <br /> L I c - <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 F HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: RS <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />