Laserfiche WebLink
PUBLIC HEALTH SERVICES-ENVIRONMENTAL V�ALTH DIVISION <br /> SITE NAME " , ADDRESS /i 3D �" CITY <br /> OWNER NAME pu to Q WNER PHONE # <br /> CONTRACTORAdv. &w&w. CONT. PHONE # a 0 9 7- 0 Q <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE L� J- j TANK # 39 6 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE /9 Mgp i C am <br /> S a � <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y)N) METHOD Q j CIO-- AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) 2of <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POORt OLE <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T � <br /> A Nh_ <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A 11 — <br /> M DEPTH I 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 /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />