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PUBLIC HATH SERVICES-EYVIRONMENTAL *tALTH DIVISION <br /> SITE NAME`SM PADDRESS f ',�(� �, �Q� CITY4v'ylc <br /> OWNER NAME VOrO { OWNER PHONE <br /> CONTRACTOR i�OCO 0 CONT. PHONE #� <br /> FIRE PERMIT 24 y'g'- ' C <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR'S -a .S DATEId TANK .4 39 6�2 ZT Sy 29� <br /> R RINSED Y N) METHOD vg r� 3, <br /> ' `t" k ) ` 0601 RINSE AMOUNT Sao <br /> I IA ✓ha <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (YIN) (METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : ff 02: L <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL <6TE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) �/n F lVU <br /> S <br /> T PIPE MATERIAL STE FIBERGLASS, OTHER) .4 FEET <br /> PIPE CONDITION (GOOD, (&OR HOLES) Aysle , 3 e 'fid <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A ll <br /> N rr n <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 1 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> -� EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />