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PUBLIC HzAL1y..3ERVICBS-ENVIRONMrITAL ,�3 DIVISION <br /> SITE NAME °�{ ADDRESS <br /> l-"%Oocr CITY <br /> OWNER NAME IOWN--R PHONE <br /> CONTRACTOR �+o l` ( CONT. PHONE 'E <br /> 9-43- -4-4(13 <br /> FIRE PERMIT r - C�IvOCZc� <br /> REMOVAL CLOSURE IN PLACE T �ORARY CLOSURE <br /> IINSPECTOR � �\�� DATE C' CNK > 3 9 a pJ <br /> R RINSED ©/N) I 2—'Hoo RINSE AMOUNTS <br /> I <br /> N RINSATE DISPOSAL SITE QRG <br /> S <br /> E MANIFEST # 9(QO5Z-y0"j OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD �� � IAMOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : 102 : O <br /> R COMMF.ENTS al d c��n �c�onc� dax c. <br /> C TANK MATERIAL -S-, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLE ) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) Ip FEET A(A <br /> PIPE CONDITION (GOOD, POOR, HOLES) /vA <br /> DEPTH ( SOIL TYPE IOBSER.VATION ( SAMPLE 0 <br /> T <br /> A r �S <br /> N I I or g Z <br /> K <br /> I <br /> S EXCAVATION SIZE X X11 ( 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 I YDS OF S07- <br /> DEPTH TO G.W. : 'C lYZ. FT. ( SAMPLING MP7HOD <br /> fi <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> .�J LABORATORY: I SAMPTZRS NAY <br /> CLOSURE IN PLACE I MIXTURE: I VOLUM^: ' <br /> EH 23-0043 (REE 2/23/94) PROVIDE SITE MAP <br />