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PUBLIC Hl TH SERVICES-ENVIRONMENTAL ALTH DIVISION <br /> SITE NAME C. o. L ADDRESS S. a� I,r `� CITY Lca <br /> OWNER NAME G L OWNER PHONE <br /> CONTRACTOR p G CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL �' CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE elllp%, SP TANK .4 39 <br /> R RINSED (YlaW METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED METHOD q�yj �� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : p 02: p <br /> 0 <br /> R COMFITS <br /> C TANK MATERIAL S FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POO , HOLES) <br /> S �. <br /> T PIPE MATERIAL STE , FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, OOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION ( SAMPLE <br /> T ! 7fo <br /> K <br /> i <br /> S EXCAVATION SIZE ' f57� X -;44-X ^�' YDS OF SOIL 7S t •Ttry�_ <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 <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> jLABORATORY: G df+4i lA> SAMPLERS NAME: kA- �✓� �F��� <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />