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PUBLIC HEAL'T'H SERVICES—ENVIRONMENTAL HEALTH DIVISION <br /> SITE N �' °�' i ADDRESS uu � CITY <br /> OWNER PHONE # 9p c/ 3 �r62. <br /> —J <br /> CONTRACTORI,44 ',Sgr &V, CONT. PHONE <br /> FIRE PERMIT # (� —/ Z-S Cy S <br /> REMOVAL ✓ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR lIrCLJ, ;K- DATE 7--y- TANK # 39 SE ASO Z <br /> R RINSED (ON) METHOD �� �� ��s� RINSE AMOUNTS7:;' <br /> I <br /> N RINSATE DISPOSAL SITE'6y'v ro,`r tj"r , /133!/ ✓' H`Jr 133 , Qn crscn, , n¢ yS3 63 <br /> S <br /> E MANIFEST # 23017653 OR OTHER <br /> V VAPORS PURGED �N) METHODS _ AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : Q <br /> 0 <br /> R COMMENTS %°,•„Ni_ "--o p*e' Ga—0—+A <br /> C TANK MATERIAL STE FIBERGLASS, OTHER) Z'S70 <br /> 0 <br /> N TANK CONDITION (GOOD, GHOLES) <br /> S <br /> T PIPE MATERIALTE FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, P5 HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A —odg <br /> N <br /> K <br /> S EXCAVATION SIZE X XS YDS OF SOIL Zc7 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> Ll 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: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />