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PUBLIC H2,TH SERVICES-ENVIRONMENTAL .:ALTH DIVISION <br /> SITE NAME ADDRESSZ CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR CONT. PHONE ig <br /> FIRE PERMIT 0 I _ <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANIC 39 �q�p 07 <br /> R RINSED &N) METHOD-� �� W =oa RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED tS?N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOO , HOLES) <br /> S <br /> T PIPE MATERIAL ( E FIBERGLASS, OTHER) 0 FEET 3 T� <br /> PIPE CONDITION (GOOD,�O�� �>HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T 2w E <br /> A tf h <br /> N <br /> K <br /> S EXCAVATION SIZEX �ti X � YDS OF SOIL11 ZC <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />