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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAMFY� r /n ADDRESS CITY' <br />OWNER NAME OWNER PHONE I .ln <br />CONTRACTOR 1 CONT. PHONE <br />FIRE PERMIT <br />REMOVAL CLOSIIRE IN PLACE TLFo-2ORARY CLOSURE <br />INSPECTOR�G �r <br />�� <br />TANK <br />R <br />I <br />N <br />S <br />E <br />RINSED (Y/N) METHOD I RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />MANIFEST at OR OTHER <br />VAPORS PURGID(5jN) !METHOD �AMOUNT USED <br />READING AT REMOVAL L.E.L.: ,S� 102: <br />COMMENTS <br />V <br />A <br />P <br />0 <br />R <br />C <br />TANK MAT (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 (OBSERVATION SAMPLE <br />I I <br />I I <br />EXCAVATION SIZE X % <br />(YDS OF SOIL <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />I <br />TRENCH DIMENSION X Y <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SAMPLLVG METHOD <br />H <br />2 <br />$ HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />I SAMPT,ERS NAME: <br />CLOSURE T"N PLACE MI:KTURE: <br />I VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />