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PUBLIC HEPTTH SERVICES—ENVIRONMENTAL HF,ALTH DIVISION <br /> SITE NAMEn'S ��w � ADDRESS3L(;/ 5 F"E' je � CITY <br /> OWNER NAME _ OWNER PHONE # <br /> CONTRACTORVI/G W, ICONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED (KN) METHOD RINSE AM0UNT�'53o0 <br /> I ti <br /> N RINSATE DISPOSAL SITE 'S� P <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED ON) METHOD C� AMOUNT USED / <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : �7 <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL ( TEEL,', FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD,, POOR,) HOLES) <br /> S `_ <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, 00 , HOLES) �jc e� �JcU/�6LSAS p �/rC�57� <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T 6r C f<71 t <br /> N t <br /> K U <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 <br /> G <br /> TRENCH DIMENSION 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 /> IFCLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />