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PUBLIC HEPT•TH SERVICES-ENVIRONMENTAL FvALTH DIVISION <br /> SITE NAME `T" ADDRESS A3mt CITY ' <br /> OWNER NAME �S qv OWNER PHONE <br /> CONTRACTOR �A c G� CONT. PHONE <br /> FIRE PERMIT # ?'O-016) <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR "�_ DATE/- / TANK # 39 Q �— <br /> R RINSED Y N) METHOD C9at&v-r &0 .- RINSE AMOUNT -Fpo <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : a 02. 5 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD OOR HOLES) P <br /> S <br /> T PIPE MATERI (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, OR, OLES) v- 2cz no <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> 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 # 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 />