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PUBLIC HEALTH -SRVICES-ENVIRONMENTAL HEAImTi DIVISION <br /> SITE NAME,,,, <br /> S t��Nn ADDRESS ;Ci ACN`I CITY <br /> OWNER NAME c .o. S OWNER PHONE # 9 3 �Z <br /> CONTRACTOR S CONT. PHONE # -� � 1I4 SH - 13CX) <br /> FIRE PERMIT # <br /> REMOVAL V/ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR Rw�\' DATE S^ �h-�'y TANK # 39 6r-01 <br /> R RINSED ) METHOD 3 rc4 5e RINSE AMOUNT O s� <br /> I <br /> N RINSATE DISPOSAL SITE 2 <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED &I) METHOD C e AMOUNT USED J �� <br /> A � 02: <br /> P READING AT REMOVAL L.E.L. : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) esob est <br /> 0 <br /> N TANK CONDITION (GOO , POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL FIBERGLASS, OTHER) # FEET Z �� fi5ci <br /> PIPE CONDITION (GOOD, 00 , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A -O ; a, O o o✓ <br /> N <br /> K <br /> S EXCAVATION SIZE 2 X 7 5 X 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: oG} G <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />