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PUBLIC HEALT' SERVICES-ENVIRONMENTAL HEP'.TH DIVISIONq.Do.-(j;070 <br /> SITE NAMF' * <br /> ADDRESS � CITY ( 60, <br /> OWNER NAME Y1� ' OWNER PHONE # Z - Z <br /> CONTRACTO1Y�hY� VQ4• CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE ff TEMPORARY CLOSURE <br /> INSPECTOR DATED )J TANK # 39 v <br /> f/ r <br /> R RINSED (Y N) METHOD RINSE AMOUNT/6QQ� I �� <br /> I <br /> N RINSATE DISPOSAL SIT <br /> S <br /> E MANIFEST # ZZ O2 OR OTHER <br /> V VAPORS PURGED Y/ ) METHOD AMOUNT USED O rbrj <br /> A ��" 02 : <br /> P READING AT REMOVAL L.E.L. : <br /> R COMMENTS 50,c++ SMlyK haA"I <br /> C TANK MATERIAL (STEEL FIBERGLASS, OTHER) <br /> 0 1-Z6A". <br /> N TANK CONDITION (GOO R, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET . V <br /> PIPE CONDITION (GOOD, POOR, HOLES) 1,(mrvvrwvl <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> APJ7- C- <br /> N <br /> K <br /> S EXCAVATION SIZE X X I -1 YDS OF SOIL lV �53 <br /> ASAMPLE # <br /> M DEPTH SOIL TYPE OBSERVATION <br /> P P VI owrlV <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> HL <br /> 2 # HOURS SINCE DEWATERING: Yj 0 <br /> 0 OTHER SAMPLE: b 1 a(f= !w I W Z 4K <br /> LABORATORY: �� SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />