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PUBLIC HEk�TH SERVICES-EV=oNMENTAL Bl!�ALTH DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME (OWNER PHONE <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT i <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR/ DATE a6 � Q'4l TANX 0 39 �L <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD 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 ,y <br /> N TANK CONDITION (GOOD, OOR HOLES) rUSfQoC p � n <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH ISOIL TYPE OBSERVATION SAMPLE <br /> T <br /> N I <br /> I � <br /> R <br /> I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SA14PLE 0 <br /> P P <br /> L I I <br /> I P <br /> N E <br /> G <br /> TRENCH D12ME ISION 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: I SAMPLERS NAME: <br /> IF CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />