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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESSd,Yaa b.SGO c <br />CITY G� <br />OWNER N Derer nis,� S�e� <br />OWNER PHONE $ <br />CONTRACTOR /-/ S <br />CO PHONE # <br />FIRE PERMIT _ <br />F�i r e im3 G%� Ron, Hl /-r-sc1,AAv <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR L-¢'fI c`" <br />DATETANK # 39 —� <br />R <br />RINSED Y N) METHOD <br />RINSE AMOUNT <br />N <br />RINSATE DISPOSAL SITE <br />S <br />tvu5te, <br />E <br />MANIFEST # <br />OR OTHER <br />V <br />A <br />VAPORS PURGED (Y N) <br />METHOD AMOUNT USED <br />P <br />READING AT REMOVAL <br />L.E.L.: 02: <br />0 <br />R <br />p <br />COMMENTS cki[ OC r, y <br />�e o r'� )n) UJ <br />By t C.a_ �9� <br />C <br />0 <br />TANK MATERIAL TEFL, <br />FIBERGLASS, OTHER) %a -K02. <br />N <br />TANK CONDITION (GOOD, <br />OOR HOLES) <br />4trHect, <br />S <br />T <br />PIPE MATERIAL (STEEL, <br />FIBERGLASS, <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) v%tStc� <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE if <br />T <br />A <br />- 7 <br />N <br />K <br />CE <br />S <br />EXCAVATION SIZE X X _� <br />YDS OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />P <br />L <br />P <br />I <br />_ <br />I <br />P <br />44 <br />E <br />N <br />G <br />TRENCH DIMENSION <br />X X YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPLING METHOD <br />H <br />2 <br />f HOURS SINCE DEWATERING,: <br />O <br />OTHER SAMPLE: �ipG� f e tS <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />