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PUBLIC HEPTH SERVICES-ENVIRONMENTAL qlALTH DIVISION <br /> SITE NAME f4NNF N ADDRESS i �4 CITY <br /> OWNER NAME (OWNER PHONE <br /> CONTRACTOR (Ji T C CONT. PHONE ` <br /> FIRE PERMIT 4 <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY 4CLOS7UREINSPECTOR I-i f DATETANK 0 39 -- <br /> R RINSED { N) METHOD R <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y7N) METHOD <br /> A L/ _ AMOUNT USED 7e)1bS <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL :STE, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR HOLES) RqS 2 21 c.<' <br /> S <br /> T PIPE MATERIAL (;STEEL FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, OOR HOLES) L (JD lkl,5; le p les <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE 44 <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLEP P _ <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> H MP <br /> DEPTH TO G.W. : FT. SALING METHOD <br /> 2 #` HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: �� C K <br /> LABORATORY: ShE(� woo 4-0j3S SAMPLERS NAME: �' e c <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />