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PUBLIC HEI -_.H SERVICES -ENVIRONMENTAL k.... LTH DIVISION <br />SITE NAME 01 ID <br />ADDRESS �1fL�� N p�(�(Qp <br />CITYS4LlG/)�Qv�� <br />OWNER NAME F11ultl� S <br />I OWNER PHONE # <br />CONTRACTO J�nCaD <br />CONT. PHONE <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR (P� `� $ DATE �0�� 9�p TANK 39 3 <br />R <br />I <br />N <br />S <br />E <br />RINSED (Y ) METHOD RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR OTHER <br />V <br />VAPORS PURGED (Y N) <br />METHOD D R� <br />AMOUNT USED)`�C <br />/ <br />A <br />P <br />READING AT REMOVAL <br />L.E.L. ��� <br />R <br />x/02: <br />COMMENTS 1 , 011Xj 9YJ ' C� <br />C <br />TANK MATERIAL TEEL FIBERGLASS, OTHER) <br />N <br />TANK CONDITION OD POOR, HOLES) <br />F" �4 ,r * nisi' Peg <br />S <br />T <br />PIPE MATERIAL FIBERGLASS, OTHER) To <br />L+] K <br />AFEET <br />PIPE CONDITION (GOOD, P�O�� HOLES) <br />T <br />A� <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />S <br />N <br />K <br />EXCAVATION SIZE X X <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />I <br />P <br />I <br />P <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <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 />x <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: StbG7 / 02 3J <br />LABORATORY: 6,2Z Cu C <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE'VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />