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PUBLIC HE".TH SERVICES -ENVIRONMENTAL "EALTH DIVISION <br />SITE NAMEJyL <br />ADDRESS �6Z� �6�„/ <br />CITY' <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTORZ,w 7✓P�� <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVAL 1✓ CLOSURE IN PLACE TEMPORARY CLOSURE <br />) OZ - <br />INSPECTOR _5�_ee7x_ DATE �/( y TANK # 39 __Lj) <br />R <br />I <br />N <br />S <br />E <br />RINSED (j`/N) METHOD j Je /j�� RINSE AMOUNT. <br />RINSATE DISPOSAL SITE /J m/n T f <br />eS <br />MANIFEST # 9�'l5 y3z5 OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED N) METHOD T AMOUNT USED <br />READING AT REMOVAL L.E.L.: / 02: <br />COMMENTS , %1114 GE I Oz, iJ A114 Ote <br />C <br />TANK MATERIAL STEE , FIBERGLASS, OTHER) <br />O <br />N <br />TANK CONDITION (GOODPOO , HOLES) <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 />T3 <br />n <br />A <br />N <br />K <br />S <br />11 <br />EXCAVATION SIZE X , X <br />YDS OF SOIL <br />A <br />M <br />DEPTH <br />SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />, <br />-- — <br />L <br />I <br />u 11 <br />I <br />P <br />� <br />N <br />E <br />G <br />Ll <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: N <br />0 <br />OTHER SAMPLE: <br />LABORATORY:C Q4 <br />SAMPLERS NAME:L <br />CLOSURE IN PLACE <br />MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />