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PUBLIC H A.�; SERVICES-ENVIRONMENTAL F—'- TH DIVISION <br /> SITE N (ADDRESS S f I CITY-94 Y'!Tw <br /> OWNER NAME (OWNER PHONE r <br /> CONTRACTOR i ( CONT. PHONE .4 <br /> FIRE PERMIT ;r <br /> REMOVAL CLOSURE IN PLACE X, TEMPORARY CLOSURE <br /> ZNSPECTOR '� DATE Lt <br /> If: i -DI TANK # 39 0166 Zl TKS <br /> R 1LTNSID N) bC7HOq -3 G �" I RINSE AMOUNT <br /> I ��Cc �v <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST P OR OTHER <br /> V VAPORS PURGED (YJ& IMETEOD/VA Tei t IAMODNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : i 02: <br /> 0 <br /> R CO S? =/4-e/J1'l.�l� = a• <br /> C TAK MATT FIBERGLASS, O'-=) � I <br /> 0 I , ©. Pe <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERZ3LSTEEL FIBERGLASS, OTHER) Ir FEET I <br /> PIPE CONDITION (GOOD, n <br /> DEPTH I SOIL TYPE I OBSERVATION SAI•KPLE # <br /> T I <br /> AI <br /> N I <br /> R <br /> i <br /> S EXCAVATION SIZE X X YDS OF SQ=L <br /> A <br /> M DEPTH SOIL TYPE (OBSERVATION ( SAMPLE r <br /> P P <br /> L I I I <br /> I P <br /> N E I I I <br /> G I I <br /> TRENCH DIMENSION X X IIDS OF SO_T" <br /> DEPTH TO G.W. : FT. ISAMPLITG TROD <br /> E I2 ¢ HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAIL1OL2-"�S NAME: <br /> CLOSIIRE IN PLACE M= TURZ• �'�� um : I J� Jl <br /> EH 23-0043 (REV 2/23/94) PROVIDE SIV_ MAP <br />