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PUBLIC HPTLTH SERVICES-ENVIRONMENTAL VEALTH DIVISION <br /> SITE NAME -BELL ADDRESS,�3oo CITYS fOG <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR r� CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMP ORARY CLOSURE <br /> INSPECTOR DATE ,a-96 TANK 0 39 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER S <br /> V VAPORS PURGED J/N) METHOD DP, Le- AMOUNT usED l5 lb-s <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : C, <br /> 0 <br /> R COMMENTS Q, F( F�' <br /> C TANK MATERIAL (STEEL, ERGLASS), OTHER) <br /> 0 <br /> N TANK CONDITION OD, POOR, HOLES) <br /> Ss A r ad- <br /> T PIPE MATERIAL (STEEL,( FIBERGLASS, OTHER) � FEET I°!Qe <br /> PIPE CONDITION GOOD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION ( SAMPLE <br /> T <br /> A Sr I l cv s — <br /> N 3 — <br /> Kt <br /> Sj EXCAVATION SIZE X X YDS Or 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 Of HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: Pte`�4" Toch-W Io SAMPLERS NAME: r <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />