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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAMY// t l7 ADDRESS <br />OWNER NAMEe DOWNER PHONE € (^J <br />CONTRACTOR -f-&�paA- CONT. PHONE # , <br />FIRE PERMIT P <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATB� # 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 />MANIFEST € OR OTMER <br />V <br />VAPORS PURGED57/N) <br />IMETHOD � / �_ AIMOIINT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: 102: <br />0 <br />R <br />C <br />COMMENTS <br />TANK MATERIAL (STEEL, IBERGLASS, 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 />I I <br />S <br />A <br />N <br />K <br />EXCAVATION SIZE X X IYDS OF SOT_L <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 ISAMPLE r <br />TRENCH 0124ENSION X X YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: I SAMPLERS NAME: <br />CLOSURE IN PLACE I MIXTURE: <br />VOLUME: <br />EH 23-0043 (-_EV 2/23/94) PROVIDE SITE MAP <br />