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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAMF�✓� [ , <br />ADDRESS �, /1 CITY <br />OWNER NAMEiJ <br />OWNER PHONE <br />CONTRACTOR <br />CONT. PHONE 0:;-03 <br />FIRE PERMIT <br />REMOVAL_Z CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR 'S D C -,,r TAMC # 39 <br />R <br />RINSED (Y/N) <br />METHOD <br />RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST # OR OTHER <br />VAPORS PURGED C(�JN) METHOD J fes- r1MOIINT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: / 102: <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL STS' 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 />DEPTH SOIL TYPE (OBSERVATION (SAMPLE <br />T <br />A <br />N <br />I I <br />I <br />S <br />K <br />I <br />EXCAVATION SIZE X 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 A <br />I i <br />zVCH DINSION X X <br />TR�_E <br />YDS OF SOIL <br />H <br />2 <br />DEPTH TO G.W.: FT. <br />(SAMPLING METHOD <br />t HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: I SAMP7ERS NAME: <br />CLOSURE IN PLACE <br />MIYTIIRS: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SIT- MU\P <br />