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PUBLIC HEATTH SERVICES-ENVIRONMENTAL HFALTH DIVISION <br /> SITE NAMEDUrc,n � ADDRESS Z-j S �1 ( v CITY <br /> OWNER NAME •( OWNER PHONE if <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT 0 ( _ 250 <br /> REMOVAL CLOSURE IN PLACE _ TEMPORARY CLOSURE <br /> INSPECTOR DATE ,5 1O TANK f 39 Z3 Z12- <br /> R RINSED nY N) METHOD RINSE AMOUNT / <br /> Z <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER A W - 3/Q <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : O 02 : 2-3 Clo <br /> O <br /> R COMMENTS <br /> C TANK MATERI ( TE , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL TEEL FIBERGLASS, OTHER)) r# FEET <br /> N Z <br /> PIPE CONDITION (GOOD, POOR, HOLES) ru 9-h-,d <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A 001 <br /> N <br /> K <br /> S EXCAVATION SIZE X — X — YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E i <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHODS! R S <br /> H <br /> 2 f HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: ` J <br /> CLOSURE IN PLACE MIXTURE: Ibgq C2w44d- VOLUME: S,3 <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />