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PUBLIC HEAT-H SERVICES-ENVIRONMENTAL H`=H DIVISION <br /> SITE NAME O hevror) ADDRESS <br /> v <br /> OWNER NAME /' he v r6 r) OWNER PHONE # <br /> CONTRACTOR C Vk" V\�S-} CONT. PHONE # <br /> FIRE PERMIT # CN_5 I <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ��� } MQL1 DATE 3 . IS .lq TANK # 39 113 Q5 <br /> RRINSED ON) METHOD -�r i RINSE AMOUNT 2 <br /> I <br /> N RINSATE DISPOSAL SITE <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (DN) METHOD �v AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : Io q& 02 : 19a <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STE <br /> 0 EL FIBERGLASS, OTHER) *uick54 <br /> N TANK CONDITION (GOOD, POO , HOLES) RvS �a <br /> S <br /> T PIPE MATERIAL STEEL FIBERGLASS, OTHER) # FEET s <br /> PIPE CONDITION (GOOD, POOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION MSAMPLETAN <br /> K GheSL(10 <br /> S EXCAVATION SIZE P X X YDS OF SOIL 50 <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 b5GMh&r_ LUC. <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME:-"k4IF— � <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />