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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAMFf✓ ln^ ADDRESS s7w/ CITY <br />OWNER NAME OWNER PHONE ./ <br />CONTRACTOR CONT. PHONE # Q SJ O <br />FIRE PERMIT iE I � <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR D . G,� TANK # 39 <br />R <br />I <br />N <br />S <br />E <br />RINSED (YIN) METHOD I RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />MANIFEST OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED(5)N) (METHOD (AMOUNT USED <br />READING AT REMOVAL L.E.L.: 02: <br />COMMENTS <br />C <br />TANK MATERIAL (STE FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, POOR, HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) I# FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />S <br />T <br />A <br />N <br />K <br />DEPTH (SOIL TYPE IOBSERNATION (SAMPLE <br />I I <br />EXCAVATION SIZE X % <br />YDS OF SOIL <br />A <br />M <br />IDEPTH <br />SOIL TYPE IOBSERVATION SAMPLE <br />P <br />P <br />i <br />L <br />I <br />N <br />G <br />I <br />P <br />E <br />TRENCH DIMENSION X Y (YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. (SAMPLING 1Z7HOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAiti:E: <br />CLOSURE IN PLACE <br />MI.{TIIRE: <br />I VOLUME: <br />EH 23-0043 (BEV 2/23/94) PROVIDE SITE MAP <br />