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T)TfRT.TC HEP.TTH SMZV7CES—EN=ONMENTAL HEALTH DIVISION <br />SITE NAME/' <br />OWNER NAME Pr <br />ADDRESS CITY <br />(OWNER PHONE # Q 3� <br />CONTRACTOR C / <br />CONT. PHONE <br />FIRE PERMIT <br />— <br />REMOVAL CLOSURE IN PLACE _ _ ` TE.`D?ORARY CLOSURE <br />INSPECTOR T_�NK # 39 <br />R RINSED (Y/N) `�'THOD I RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST at OR OTHER <br />V <br />VAPORS PURGEDN) (METHOD ��� <br />AMOUNT USED <br />A <br />P <br />READING AT REMOVAL L.E.L.: <br />02: <br />0 <br />R <br />C <br />COMMENTS <br />TANK MATERI3L TEES„ FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, 0 , 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 />- s - <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 P <br />TRENCH DIMEiSION 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: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />a=TURE: <br />I VOLUME:11 <br />E.ti 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />