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PUBLIC HEAL?fi SERVICES-ENVIRONMENTAL Hl=TH DIVISION <br /> SITE Ne ` " S ADDRESS 6 -7 � y J-LLGAE G �i/P1C I CITY,��j <br /> G v <br /> OWNER NAME 1 rv.Ce�wS<.h OWNER PHONE <br /> CONTRACTOR ( CONT. PHONE # <br /> FIRE PERMIT s <br /> REMOVAL CLOSURE -TN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 l 71` <br /> R RINSED (YIN) METHOD R7-NSE AMO <br /> I � <br /> N RINSAT_E DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (YIN) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : 9 7 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) l 6f5j¢ _ q5 fq <br /> 0 p,4_� <br /> N TANK CONDITION (GOOD 00 HOLES) O r I't S f l/ A D V/S l L2 e- <br /> S <br /> T PIPE MATERIAL TE FIBERGLASS, OTHER) Ir- FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) 41 <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T I I I <br /> A <br /> N � r <br /> K <br /> ft <br /> S EXCAVATION SIZE X X YDS OF SOIL <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 I2 rx HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> i <br /> LABORATORY: I SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: ( VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />