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PUBLIC HEAI,T'H SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE AMADDRESS// I, Corywr N^" f�t� CITY <br /> OWNER PHONE <br /> CONTRACTOR S CONT. PHONE 3 J X <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR � DATE 7-11_1TANK # 39 <br /> R RINSED N) METHOD '� �y � A RINSE AMOUNT $O <br /> 2gul <br /> N RINSATE DISPOSAL SITE �I`J'�/�U �+n�i /333 /✓ y33� <br /> S /J <br /> E MANIFEST O/ 76 OR OTHER <br /> FPVAPORS PURGED ®/N) METHOD TL.,__ AMOUNT USEDSa /6 <br /> READING AT REMOVAL L.E.L. : 0 02: e <br /> 0 1 � ' <br /> R COMMENTS /p� Cc-4 u- , <br /> C TANK MATERIALSTE , FIBERGLASS, OTHER) Z S O / • <br /> 0 <br /> N TANK CONDITION (GOOD, (&, HOLES) <br /> S <br /> T PIPE MATERIAL (STE , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, 60l HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T IT <br /> A — o S <br /> N <br /> K <br /> S EXCAVATION SIZE _Z1 X X S YDS OF SOIL Zed <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: S SAMPLERS NAME: lja_4� 6(vt4— <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />