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PUBLIC HV7TH SERVICES—ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME f,�LL,5t? 7 <br />ADDRESS 165-.2, <br />CITY <br />OWNER NAME Nps <br />OWNER PHONE <br />CONTRACTOR G� <br />� <br />CONT. PHONE <br />FIRE PERMIT # <br />REMOVAL CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR DATE TANK # 39 <br />R RINSED (YIN) METHOD OUNT <br />I <br />N <br />-- <br />RINSATE DISPOSAL <br />-- <br />E <br />MANI <br />OR <br />OTHER <br />V <br />P <br />0 <br />R <br />VAPORS PURGED (YIN) <br />READING AT REMOVAL <br />COMMENTS <br />METHODe221 <br />L.E.L.: <br />I AMOUNT USED �p 5 <br />L�016 • 02: J(� <br />C <br />TANK MATERIALSTEEL, <br />BERGLASS, <br />OTHER) <br />0 <br />N <br />TANK CONDITIO D, <br />POOR, HOLES)�� <br />n' �p /� <br />b IIS I �' <br />S <br />T <br />PIPE MATERI <br />FIBERGLASS, <br />OTHER) <br /># EET <br />PIPE CONDITION ( , <br />POOR, HOLES) <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />Tlnl� <br />5 <br />I b <br />A <br />N <br />S <br />EXCAVATION SIZE <br />_ X X <br />YDS OF SOIL <br />A <br />M <br />P <br />P <br />DEPTH SOIL TYPE <br />OBSERVATION <br />— SAMPLE`# <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION <br />X <br />X <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPL <br />H <br />2 <br /># HOURS SINCE DEWATERI <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME —� <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />