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PUBLIC HEALmH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITI! <br /> aon o xk_h-- ADDRESS Ccvr CITY <br /> c <br /> OWNIR c "' °/'G OWNER PHONE <br /> CONTRACTOW,,.4 CONT. PHONE <br /> FIRE PERMIT # ZS e '5 <br /> REMOVALS CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ,�,,j DATEY TANK # 39 <br /> R RINSED N) METHOD C /� RINSE AMOUNT So <br /> I ' <br /> N RINSATE DISPOSAL SITE CJ^v/%r°� 1,1"��i /33 3 J aJ, 7 3 3, " C'(- . , c-& 5 S3 6.$ <br /> S <br /> E MANIFEST # 53 O/ 76 5 3 OR OTHER <br /> V VAPORS PURGED (DN) METHO f pL�_ AMOUNT USED So 6141 <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS q..k az-o d &rl_� . <br /> C TANK MATERIAL t TE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, HOLES) <br /> S <br /> T PIPE MATERIAL (CT*, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, P O , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A o a 3 <br /> N <br /> K <br /> S EXCAVATION SIZE X X �� YDS OF SOIL 7_0 <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: q{ SAMPLERS NAME: t6�L 6 rvc"L <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />