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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME - a i.. .r ADDRESS /-Z S h/�� f`�Gf CITY <br /> OWNER NAME pGE OWNER PRONE # <br /> CONTRACTOR G CONT. PHONE # <br /> FIRE PERMIT g115,I r <br /> REMOVAL Y CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR - !/mss DATE TANK t 39 Sy7S 'I 6� <br /> R RINSED (Y/fTp METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (VN) METHOD AMOUNT USED n <br /> A <br /> P READING AT REMOVAL L.E.L. : C 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, ( , HOLES) <br /> S <br /> T PIPE MATERIAL (ST , FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, (i00 ) HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> Av vDu2 a Sv, oA f3 - <br /> N � i3' I n = - <br /> K <br /> S EXCAVATION SIZE -Vy� X -Z--/'X /o' YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> 3'4 <br /> N E 5q �/ G��J cow v Ste• �cc,cvs3ario,� - Z <br /> I P 50. c Lv vdrL Ss. . rsc7..,,.44777 <br /> G <br /> TRENCH DIMENSION — X - '3' X 3 YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: A"!D SAMPLERS NAME: )cA-r-14y,�-�� <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />