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PUBLIC HEAL''T SERVICES—ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME i e B ADDRESS J CITY � - <br /> OWNER NAM OWNER PHONE <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT # / <br /> R OVAL_Lz CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE 6 .�,/ TANK # 39 <br /> R RINSED CY,/N) METHOD l e ��. f RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED &/N) IMETHOD Zc_ AMOUNT USED/03 q _3 <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTSAm /V)/5�+-,rt- ) %S <br /> C TANK MATERIAL ( ,TE FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAL TE , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T Z - C-tc 2 Qc cr <br /> N7n r c of <br /> K <br /> S EXCAVATION SIZE /& 'X � X _ YDS OF SOIL <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: �Z< SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />