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ruD{..1�. nGHA1R AGKV1l:LS C,NV1tcUNP1C;N'l[iL riC;AL1'ri UlV1J1UN <br /> SITE NAME In�I ," ' ADDRESS 222 !R- CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR G CONT. PHONE - <br /> FIRE PERMIT( # <br /> REMOVAL /v CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR—F — DATE <br /> R RINSED ( ) METHOD Zo + RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y ) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 0 �D 02 : 3 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (TEEl, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET zr:r <br /> PIPE CONDITION (GOOD, 0 , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T l=r <br /> A i�s i v cJ <br /> N <br /> K <br /> S EXCAVATION SIZE �ppyX 32 F+ X YDS OF SOIL 150 c(5 <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: �v�lbm ins S — <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />