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PUBLIC HEALT2' SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ��� ADDRESS ✓/ ! /l CITY <br /> %° <br /> OWNER NAME OWNER PHONE # <br /> CONT RACTO �D� Uf� CONT. PHONE # L/Lf/, <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED (Y N) METHOD RINSE AMOUNT y� <br /> IDISPOSAL0✓�� <br /> N RINSATE / SITE ,� n // <br /> E MANIFEST # ��� /��J OR OTHER rADDX.�IU� L? <br /> V VAPORS PURGED ©/N) METHOD AMOUNT USEDD <br /> pd/f 02: D <br /> P READING AT REMOVAL L.E.L. : <br /> O !� <br /> R COMMENTS <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) —zq <br /> 0 <br /> N TANK CONDITION (GOOD HOLE <br /> S / <br /> OTHER) # FEET <br /> T PIPE MATERIAL STE , FIBERGLASS, / <br /> PIPE CONDITION GO , POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A 71 sC S Z <br /> 7 s, <br /> N � a ; <br /> K <br /> S EXCAVATION SIZE X S X YDS OF SOIL <br /> ASAMPLE # <br /> M DEPTH SOIL TYPE OBSERVATION <br /> P P o <br /> L I <br /> I P <br /> N E <br /> GX YDS OF SOIL <br /> TRENCH DIMENSION X <br /> DEPTH TO G.W. : <br /> FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: PO4 SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXT E: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />