Laserfiche WebLink
PUBLIC HEALTH 'SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME N bv¢�� d ADDRESS l�{�o0p S �� CITY �aN <br /> OWNER NAME OWNER PHONE # 5 _ W CO <br /> CONTRACTOR e 0 CONT. PHONE # � <br /> FIRE PERMIT # <br /> REMOVAL_X _ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSP'tCTORQ � DATE rj TANK if 39 <br /> R RINSED (Y N) METHOD�� W RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST 14JLE- OR OTHER <br /> V VAPORS PURGED Y METHODAMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERI STE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOODPOOR HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <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 /> 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 />