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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> Fti ADDRESS . CITY <br /> OWNER PHONE ¢` <br /> CONT. PHONE3y <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE q• 7.gq TANK # 39 16S2— <br /> Q3 If ' <br /> IRINSED Y/N) METHOD �� 7j v�j� RINSE AMOUNT 7 <br /> N RINSATE DISPOSAL SITE - 4t,t 3 <br /> S ��" m <br /> E MANIFEST # ` P53o/33 OR OTHER //�jT-/1(A-c_: fy 57_ 7� <br /> V VAPORS PURGED (9N) METHOD 7c.,e_ AMOUNT USED w <br /> A <br /> P READING AT REMOVAL L.E.L. : < )% 02 : <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STEEL, IBERGLASS, OTHER) 3z'Ko' <br /> 0 <br /> N TANK CONDITION GOOD POOR, HOLES) 1ca�y <br /> S <br /> T PIPE MATERIALSTE FIBERGLASS OTHER) # FEET ' yL <br /> PIPE CONDITION ((GOODPOOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T d <br /> A _ 7-3N o iacu 73 '� <br /> K <br /> S EXCAVATION SIZE tCP X I;L X11 a: IYDS OF SOIL <br /> A <br /> 0 M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P _ r <br /> I P <br /> N E i iI(p L <br /> J <br /> TRENCH DIMENSION 3(p 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: <br /> LABORATORY: SAMPLERS NAME: <br /> IF—CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />