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PUBLIC HEALRA SERVICES-ENVIRONMENTAL HFA Tg DIVISION <br /> SITE NAME G Gr'LL ADDRESSaJ&) E. CITY <br /> OWNER NAME IOWNER PHONE # <br /> CONTRACTOR�r ,�r y� CONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL__ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE�5-o�- (p(c TANK .4 39 3q 3 0,� <br /> R RINSED (Y(N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER JQ Q <br /> V VAPORS PIIRGIDC(Y N) (METHOD ( L AMOIINT IISED301 s <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: 5 <br /> 0 <br /> R COMMENTS <br /> MC TANK MATERIAL (STE FIBERG/LASS, OTHER) <br /> LS ,ITANK CONDITION GOOD, POOR, HOLES) <br /> PIPE MATERIAL (STEEL, FIBERGLAS OTHER) J # FE .s{ti p42 W TIsn 's <br /> q��, <br /> PIPE CONDITION GOOD POOR, HOLES) rF'c�. T-kqad- 11 <br /> T11 DEPTH SOIL TYPE OBSERVATION ( SAMPLE <br /> A <br /> N * - L -O <br /> K nsis. - -00';" ,'1( <br /> S d- EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE ig <br /> P P <br /> L I D <br /> I P <br /> N E S <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: SfbGK I )e <br /> LABORATORY: SAMPLERS NAME: 1 <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />