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PUBLIC HEP'.TH SERVICES-ENVIRONMENTALL FVALTH DIVISION <br /> SITE NAME " ADDRESS j0 g S, Q /Jle�,dn CITY <br /> OWNER NAMEDeW OWNER PHONE # <br /> CONTRACTOR U CONT. PHONE <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTO h[ w DATE I .��p�R TANK ¢ 39 j <br /> R RINSED Y%N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V [READING <br /> APORS PURGED (Y N) METHOD �,c AMOUNT USED / 7G <br /> A <br /> P AT REMOVAL L.E.L. : , 02: <br /> R OMMENTS c �'Fc P�� omt 2CG ? GL£Se�c <br /> C TANK MATERI STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) o5 (/9ri� <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOODOOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE t <br /> T 'c S <br /> A <br /> N <br /> K } <br /> S EXCAVATION SIZE X c,,I, X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I EXGa <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 /> 7i <br /> LABORATORY: SAMPLERS AME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />