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Tg DIVISION <br />ow SERVIC£S-ENVIROlR4:V AZ <br /> PUBLIC H P�G �- CIT`; 5-m(-r-T014 <br /> 5Z 06-fo–Coi f <br /> D <br /> ADgEss 5151 I <br /> SITE NAME (OWNER PHONE <br /> hOWNER NAME <br /> � . CONT. PHONE � <br /> CONTRACTOR V �`' <br /> K,p,�{- t-di11u' <br /> FIRE PERMIT TEMPORARY CLOSURE <br /> CLOSURE IN PLACE <br /> gEjjOVAL� TANK # 39 <br /> DATE It x )DI <br /> INSPECTOR RINSE AMOUNT_ S� <br /> INSP 11 <br /> METHOD TIZtP�E 12�a`� i <br /> R RINSED ON) <br /> I <br /> SITE 1 GonS�'JCt�•�on <br /> N gINSATE DISPOSAL �' OR OTHER <br /> E �iIFEST # Zl DL4L4—L — AMOUNT USED Coo 1b5 <br /> �1 METHOD D r2y I c� <br /> V VAPORS PURGED 4�/N) 02 : Z so�O <br /> AL.E.L. : <br /> P BEADING AT REMOVAL <br /> 0 <br /> R CON4 S OTHER) <br /> MATERIAL (STE FIBERGLASS, <br /> C T---',Ng HOLES) G✓OM <br /> 0 GOOD POOR, <br /> N TAME CONDITION FEET <br /> S TERIAL (STEL, FIBERGLASS , OTHER) <br /> T PIPE MA <br /> ( PIPE CONDITION (GOOD, POOR, HOLES) <br /> SAMPLE � <br /> I DEPTH SOIL TYPE OBSn"RVATION <br /> of <br /> T GI loa* r t o <br /> A <br /> N 5 Kz�wr <br /> R YDS OF SOIL yc15 <br /> S I EXCAVATION SIZE X X 1� SAMPLE <br /> AI DEPTH ISDIL TYPE OBSERVATION <br /> IM I µp �Fi Nfs <br /> P P <br /> L I <br /> I A <br /> N E X YDS OF SOII <br /> G TRENCH DIMENSION X <br /> SAMPLING METHOD <br /> DEPTH TO G.W. : <br /> 2 HOURS SINCE DEWATERING: <br /> 0 OTHER SAMPLE. <br /> SAMPLERS NAME: Doua <br /> LABORATORY* K�1`l LDS VOLUME: <br /> CLOSURE <br /> IN PLACE MIXTURE. <br /> EH 23-0043 (REv 2/23/94) PROVIDE SITE MAP <br />