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PUBLIC H`LTH SERVICES -ENVIRONMENTAL TiEALTH DIVISION <br />SITE NAMES -j <br />ADDRESS <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTOR /,,)k, �� <br />CONT. PHONE # �ri9 S 59-a3 417 <br />FIRE PERMIT <br />REMOVAL ( CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR VSs DATE j// o?V TANK # 39 ii3J a1 <br />R <br />I <br />N <br />S <br />E <br />RINSED (YIN) METHOD�� k lndt RINSE AMOUNTS W <br />RINSATE DISPOSAL SITE oOg� �✓ T f <br />MANIFEST OR OTHER <br />V <br />A <br />P <br />R <br />VAPORS PURGED ( /N) METHOD ) ) (e AMOUNT USED 3b0 %t�S <br />READING AT REMOVAL L.E.L.:�V-/7j 02: <br />COMMENTS �,,,� o �. �6 <br />C <br />TANK MATERI (STEEL FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD , OLES) <br />- <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />/3 a aAr -13 <br />A <br />3aA- <br />N <br />K <br />S <br />EXCAVATION SIZE Zi'� X _L X <br />YDS OF SOIL <br />A <br />M <br />. <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />/ <br />L <br />I <br />I <br />N <br />P <br />E <br />rY <br />'24- <br />GH <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G. W. >13, FT. <br />SAMPLING METHOD <br />H <br />2 <br /># HOURS SINCE DEWATERING: fel/f) <br />0 <br />OTHER SAMPLE: <br />LABORATORY: Q� <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />