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-•-••+•-+:..�-rivv1xviV1•iC;iV'1'AL kihA.LTH DIVISION <br /> SITE NAME ADDRESS 1471i <br /> }� CITY VU C� <br /> OWNER NAME OWNER PHONE ` <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMITN99 <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE _ <br /> INSPECTO DATE6./10 TANK 0 39 <br /> IMETH <br /> RINSED (Y ) OD-P , RINSE AMOUNT55- <br /> N RINSATE DISPOSAL SITE p V`1�t � <br /> S T\ <br /> E MANIFEST R OTHER <br /> V VAPORS PURGED (Y N) METHOD AMOUNT USED )15 <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL TEEL FIBERGLASS, OTHER)40 �L e <br /> 0 v <br /> N TANK CONDITION (GOOD OOR HOLES) Ras d �� H"e - 'rlD Ise dle. <br /> S il <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE ,# <br /> T S!A <br /> N �� i <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 /> H DEPTH TO G.W. : FT. SAMPLING METHOD &CeSS +U, CS <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: ,sYv r— K I1' <br /> LABORATORY: SAMPLERS NAME: & <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />