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PUBLIC HEAI--' SERVICES-ENVIRONMENTAL HF*LTH DIVISION <br /> SITE NAME`/, r N q/aADDRESS /i`/ a` �rc vk%We <br /> CITY J <br /> OWNER NAME� OWNER PHONE I <br /> CONTRACTOR e CONT. PHONE # <br /> FIRE PERMIT / _/()l <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ] �pf� DATE 6 TANK # 39 __L_7 b Z- j <br /> R RINSED N) METHOD �jr, )I< k +< RINSE AMOUNT L,l <br /> I , <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD J 7Zc AMOUNT USED�U,3/ky <br /> A <br /> P READING AT REMOVAL L.E.L. : e(r1 02: � cD <br /> O /I t <br /> R COMMENTS 5,r <br /> C TANK MATERIAL STEE ', FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 40HOLES) <br /> S <br /> T PIPE MATERIAL EE , FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, 6ORpHOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A y� <br /> N S <br /> K S3.. o46r <br /> n <br /> S EXCAVATION SIZE �/X /Z.,' X � YDS OF SOIL �j0 Vda 7j <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 3C X X YDS OF SOIL — <br /> DEPTH TO G.W. : 4' FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY:4'a', �ua SAMPLERS NAME:IF <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />