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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAM Op(/ ADDRESS �/ <br /> YY �v CITY <br /> OWNER NAME (OWNER PHONE 0 <br /> C7 <br /> CONTRACTOR CONT. PHONE 0! q11- <br /> FIRE <br /> l FIRE PERMIT _13 �-/ G <br /> REMOVAL f CLOSURE IN PLACE <br /> TEMPORARY CLOSURE <br /> INSPECTOR DATE <br /> 7 Zr -Z STANK ,# 3 9 <br /> R RINSED Y ) METHOD C Wm RINSE AMOUNT ZS <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED Q N) METHOD eo2. AMOUNT USED SSpr+ <br /> A <br /> P READING AT REMOVAL L.E.L. : �jc, 02 : :5 la <br /> 0 <br /> R COMMENTS e C�OS� ' ezl a� <br /> C TANK MATERI (STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL FIBERGLAS , OTHER) # FEET 516 <br /> PIPE CONDITION (GOOD, POO HOLES) <br /> T DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A G� <br /> N / o uJaa <br /> K <br /> S EXCAVATION SIZE = X (0O X 15- YDS OF <br /> A SOIL p <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P £ <br /> N E <br /> G <br /> TRENCH DII$ENSION 3 X X '7�t> YDS OF SOIL < 2Od' <br /> q <br /> DEPTH TO G.W. : �50 FT, SAMPLING METHOD vl Yv <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />