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PUBLIC HEAD SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS ( CITY <br /> OWNER NAME (OWNER PHONE <br /> CONTRACTOR ( CONT. PHONE # <br /> FIRE PERMIT a <br /> REMOVAL, CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK of 39 l Y L";Z- <br /> R RINSED (Y/N) METHOD RINSE AMOUNT j C <br /> IAill <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD AMOUNT USED <br /> A o� <br /> P READING AT REMOVAL I L.E.L. : �� �L 02 : <br /> 0 <br /> R COMMENTS <br /> q rcc .kyr <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER,) /D <br /> ° D " r is v lsi� /e D <br /> N TANK CONDITION (GOOD, _OOR ,aoLEs) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE r <br /> TI I <br /> AIS ^ s <br /> N <br /> K it Rih <br /> I I <br /> S EXCAVATION SIZE X X IYDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE ( OBSERVATION SAMPLE <br /> P P ! I <br /> L I <br /> I P <br /> N E <br /> G <br /> Ll TRENCH D=SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 a HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> i <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />