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PUBLIC HEALTF SERVICES-ENVIRONMENTAL HEA7'T'H DIVISION <br /> SITE NAME �� ADDRESS 7uj Sd CITY <br /> OWNER ' 9/ OWNER PHONE # <br /> r� yo4 - -3 <br /> CONTRACTO ,d-S� � <br /> CONT. PHONE # I o S - G <br /> FIRE PERMIT #`f -/ Z3 Ci <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR�CJkTt' DATE ,�� � TANK # 39 Sa b� ' �� <br /> R RINSED Y ) METHOD RZNSE AMOUNT �y <br /> Iy <br /> N RINSATE DISPOSAL SITE �T^�'f� Pw` a°-0¢ �333� � a"!/ `331 c-rscm, (,A X5363 <br /> E MANIFEST # x3017 6 �3 OR OTHER <br /> V VAPORS PURGED /N) METHOD ��� AMOUNT USED _50 �vo <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS n J <br /> C TANK MATERIALSTEE , FIBERGLASS, OTHER) zjSO <br /> 0 <br /> N TANK CONDITION (GOOD, OR HOLES) <br /> S <br /> T PIPE MATERIAL STEO, FIBERGLASS, OTHER) # FEET p" /p <br /> PIPE CONDITION (GOOD, 00 , HOLES) ���L /oCj i' <br /> U�xxr l <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A ,S � co <br /> N <br /> K <br /> S EXCAVATION SIZE X /Z- X Z-S 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: v� <br /> LABORATORY: S p SAMPLERS NAME: M., ry <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />