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PUBLIC HEASsH SERVICES-ENVn2ONME1MXL HL6TH DIVIiSION <br /> SITEN ©� DRESS St ICITYCs LL <br /> OWNER NAME (OWNER PHONE r <br /> CONTRACTOR I CONT. ?HONE <br /> FIRE PERMIT r <br /> REMOVAL CLOSURE IN PLACE x— TEMPORARY CLOSURE <br /> If <br /> INSPECTOR DATE TANK r 39 05f 55 T <br /> R RINSED eyN) 1=OD wrx �✓ I RINSE AMOUNT <br /> N =SATE DISPOSAL SITE <br /> S <br /> E MANIFEST it OR O'T_'HZ <br /> V VAPORS PURGED (Y0 I METHOD a 3 (AMOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : 102 : aQ <br /> 0 <br /> R COMl,=-S -r <br /> C TANX MATERTXL TEFL FIBERGLASS, O <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) D <br /> S <br /> T PIPE MATERIA- . STEEL FIBERGLASS, OTHER) I s F-21= <br /> PIPE CONDITION (GOOD POOR, OLE ) `M' II <br /> DEPTH ( SOIL TYPE ( OBSERVATION ( SAMPLE r <br /> T I I I <br /> A I ct c I <br /> N <br /> S EXCAVATION SIZE X % $ YDS OF So.L <br /> A <br /> M DEPTH ( SOIL TYPE ( OBSERVATION ( SAMPLE r <br /> P P I I I <br /> L I Ijul&lft I A)o I <br /> N E I I I <br /> G I I ! <br /> TRENCH DIMENSION X X ( YDS OF SOIL <br /> EDW. : FT. ISAMPL�7G METHOD <br /> H <br /> 2CE DER TNG:0 <br /> E: <br /> &eO Gc� I SAMPLERS NAME: <br /> i <br /> CLOSIIRS IN PLACE I *r_XTURz �S VOLUME.- <br /> 23-0043 (REV 2/23/94) PROVIDE 91TE MAP <br />