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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS �j-T�� CITY <br /> 6H/fl� /L/di _ ZF <br /> OWNER PHONE # Zp� � yZ7_ Soc <br /> OWNER NAME S�/ (jv�Ld/r�� <br /> CONTRACTOR�� co ry1L CONT. PHONE # �Z ,) ej6 - 6 y <br /> FIRE PERMIT <br /> REMOVALS CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE 96 TANK # 39 ' Z 23 r <br /> R RINSED (VN) METHOD ��iPG� RINSE AMOUNT pG'/ <br /> I <br /> N RINSATE DISPOSAL SITEFi k , E S ✓1�G <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED C ) METHOD AMOUNT USED �Z l <br /> A <br /> P READING AT REMOVAL L.E.L. 02 : _ 2 <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (t`TEEL, )FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, COOI7-MOLES) <br /> S <br /> T PIPE MATERIAL (STifIL.,iFIBERGLASS, OTHER) # FEET , <br /> PIPE CONDITION (GOOD, BOOR; HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE _L_�X X 5- YDS OF SOIL z) <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: q <br /> LABORATORY: � A�lac� SAMPLERS NAME:`/Cip+f � <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />