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PUBLIC HEALTH SER7110ES-MIVIRONMENTAL HEALTH D=iSION <br /> SITE NAME Q (ADDRESS 35 ICT-TY <br /> OWNER NAME IOWNm PHONE r <br /> CONTRACTOR ( CONT. PHONE at <br /> FIRE PERMIT r <br /> REMOVAL_ CLOSURE IN PLACE T=ORARY CLOSURE <br /> INSPECTOR K,r DATE O 2 D) TANK r 39 () Z37j9 <br /> R RINSED (Y N) M--=OD I =SE IUMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> D MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) I1SETHOD (AMOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : 102 : <br /> O <br /> R COMFITS <br /> C TANK MATER?3L (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T orpE MN�.T tT-_3y (STEEL, 'T_3 GLA , OTHER) I T FEET <br /> PIPE CONDITIONGOOD, POOR, HOLES) <br /> DEPTH ( SOIL TYPE IOBSzRVATION ( SAMPLE <br /> m <br /> 1S ' I i I <br /> N 1 I 1 M; I f Z-L <br /> MuI r�Z- <br /> I I I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ISOIL TYPE IOBSZRVATION SAMPLE T <br /> L „fog C C I D I <br /> I I I I ➢Z <br /> N 2_ I w I <br /> G li I I <br /> TEENCH DIENS ON X X ( YDS OF SOIL <br /> DEPTH TO G.W. : FT. ISA2PLING METHOD <br /> H ! <br /> 2 HOURS SINCE GM <br /> 0 <br /> OTHER SAMPLE: <br /> L2 BORATOR`Y: I SAMPLERS NAIL.': <br /> CLOSURE IN PLACE M=l =URr: VOLITME: <br /> E.? 23-0043 (REV 2/23/�) PROVIDE SITE MAP <br />