Laserfiche WebLink
PUBLIC HEk,-- H SERVICES -ENVIRONMENTAL HaALTH DIVISION <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />ADDRESS <br />CITYS Gh� <br />SITE NAME v (GQ Re � <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTOR E i <br />CONT. PHONE # <br />FIRE PERMIT '02 a— <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />//X� <br />INSPECTOR KX �� j GZ� DATE �(� a - TANK i 3 9 <br />R <br />RINSED (Y <br />L <br />RINSE AMOUNT <br />N <br />RINSATE DISPOSAL SITF µ. Or t� qz) G(SfJSf OT� 10 <br />S <br />E <br />MANIFEST # O✓L OR O <br />V <br />VAPORS PURGED (Y/e <br />METHOD <br />AMOUNT USED /VA <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.E�.-r4ly <br />02: <br />0 <br />R <br />r <br />COMMENTS W RSte_ Oi I T -0n) V- <br />C <br />C <br />TANK MATERIAL STEEL FIBERGLASS, OTHER) o xp c <br />0 <br />N <br />TANK CONDITION (GOOD, POOR, OLES <br />+ .CP�Vry�lvY�Ci/ YL <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET nfp <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />T <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />A <br />N <br />S <br />K <br />EXCAVATION SIZE X X1� <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />P <br />I <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />I <br />P <br />N <br />G <br />E <br />TRENCH DIMENSION X X YDS OF SOIL <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />H <br />2 <br />/ HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: S f OG K j 1 e, S tK 1 <br />LABORATORY: Gw AYI C pSAMPLERS <br />NAME: R Am RD S R , y <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />