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PUBLIC HEA- -'U SERVICES-ENVIRONMENTAL ff 'XLTH DIVISION <br /> SITE NAME ADDRESS CITY :5;W . <br /> OWNER NAME Q✓r�A OWNER PHONE # � /`�/O <br /> CONTRACTOR4/,�515 CONT. PHONE <br /> FIRE PERMIT # C}l} ?0A) TCS <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR , DATE �/ J?9 TANK # 39 /DPL b Pu <br /> R RINSEDY N) METHOD <br /> I 2() Ac,C`,&" I RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE Vjc� � � Q,[ Crj> C4� <br /> S <br /> E MANIFEST # q 'S�/33 OR OTHER _�TVVA-* W�617i �3 <br /> V VAPORS PURGED (19N) HOD <br /> A N) MET /G6 AMOUNT USED <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS (��p., �d ewe" UST <br /> C TANK MATERIAL((SFE FIBERGLASS, OTHER) 2 <br /> O <br /> N TANK CONDITION GOOD, POOR, HOLES) _ e �� Jq r <br /> S <br /> T PIPE MATERI (STEEL IBERGLASS OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) �40 Q oD <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> TO _.o a •Z Al <br /> A <br /> NT• Z <br /> K 7"Z S <br /> S EXCAVATION SIZE X X L X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L IO isca sCh L / <br /> I P <br /> 3 ' If <br /> L Z <br /> N E <br /> G <br /> TRENCH DIMENSION X 2-L X 2 wo ale YDS OF SOIL µ` <br /> DEPTH TO G.W. : I4O FT. SAMPLING ME OD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> IF CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />