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PUBLIC HEAx TH SERVICES-ENVIRONMpENpTAL FvALTH DIVISION <br /> SITE NAME,OA ADDRESS3Q8 s. C� �p�j CITYSjG/� � <br /> OWNER NAMEOWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT # qS <br /> REMOVAL� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR kJV ` C DATE ,�6'9`) TANK # 39 Q p <br /> R RINSED Y ) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSA7i SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED /N) METHOD CRS AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : Q 02 : <br /> O <br /> R COMMENTS T qA) 0-a-1 /-4� 604? s � Eh[' k4gc <br /> C TANK MATERIAL TE FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, POOR HOLES) ` " <br /> S <br /> T PIPE MATERIAL<7TE , FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, OOR HOLES) Prlf� Jot v��o <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE _g' X ii_ X j_L_ 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: Sior-K le S '-Msp 4-13 <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />