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PUBLIC HEAa H <br /> D SERVICES-ENVIRONMENTAL Blt z ,THti DIVISI <br /> ON <br /> -3SITE NAME Ow� ARCITYS <br /> 7al <br /> OWNER NAME A CGh I OWNER PHONE � ��a( y / - 31-31 <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT s4 <br /> OSURS IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR &�lIu DATE (D -9S TANK # 39 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> 2 <br /> S RINSATE DISPOSAL SITE 5DC ,SC2/du L-;7 LG <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) D OUNT USED <br /> A <br /> P READING AT REMOVAL E.L. : 02: <br /> 0 <br /> R COMMEN'T'S <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) `- <br /> 0 <br /> N TANK CONDITION (GO POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, BERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR,-HOLES) <br /> DEPTH ( SOIL TYPE ( OBSERVATION ( SAMPLE if <br /> T I J <br /> 11 <br /> A <br /> K I I I I <br /> I <br /> S EXCAVATION SIZE X X YDS OF SOIL :5?::7 3 - <br /> A <br /> M DEPTH ( SOIL TYPE (OBSERVATION SAMPLE # <br /> P P <br /> L I I I <br /> IP I <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 1 <br /> OTHER SAMPLE: S 1 O C• I\ J 2 <br /> LABORATORY: SAMPLERS NAMY <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> E-H 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />