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PUBLIC HEAD SERVICES-ENVIRONMENTAL Htt= DIVISION <br /> SITE N +� i e ADDRESSK� 7 549 N4hh-�+�J E7c �/z ( CITY'S .- <br /> C <br /> ( OWNER PHONE <br /> L <br /> CONTRACTOR-1/l t$ L�r I CONT. PHONE # <br /> FIRE PERMIT 8 7 • <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR,}�a-t, -h'a Q 6 r S DATE TANK # 3 9 7.2-, I <br /> R RINSED (Y/ ) METHOD RINSE AMOUNT C <br /> I `1 <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E <br /> MAN=FEST # OR OTHER <br /> V VAPORS PURGED ON) IKE = AMOUNT USED Cpp� A <br /> A +�L <br /> P READING AT REMOVAL L.E.L. : 102 : l(� � <br /> 0 <br /> R COMMxENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) 3 c S Tx 1 4' <br /> 0 <br /> N TANK CONDITION (GOOD, _ O HOLES) R c4 V <br /> S <br /> T PIPE MA T=?LL (STEEL, FIBERGLASS, OTHER) r FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES)—''`- <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE ff <br /> m <br /> A IS <br /> N S <br /> K IS <br /> I � <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I I 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 s HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: �t[�' Cztw/r if tS` lPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EF_ 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />