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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME/ <br />ADDRESS 9pv/G vi�i� CITY LSO <br />OWNER NAM!2 <br />OWNER PHONE # �68_zy7Z <br />CONTRACTOR <br />CONT. PHONE <br />FIRE PERMIT #9 <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR � Fv_IA <br />DATE TANK # 39 /7 L( -Z -_ <br />R <br />I <br />RINSED Jai) METHOD <br />S RINSE AMOUNT 2 <br />N <br />RINSATE DISPOSAL SITE <br />E <br />MANIFEST # '>�9G <br />OR OTHER <br />V <br />A <br />VAPORS PURGED (5pN) <br />METHOD rcE AMOUNT USED tj om /6j <br />P <br />0 <br />READING AT REMOVAL <br />// <br />L.E.L.: 6 02 <br />R <br />COMMENTS <br />C <br />0 <br />TANK MATERIAL Si5;Lo <br />FIBERGLASS, OTHER) <br />N <br />TANK CONDITION (GOOD&.O <br />' OLES) <br />S <br />T <br />PIPE MATERIAL <br />FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />1(OO17 ,HOLES) <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />A <br />K <br />S <br />EXCAVATION SIZE � � X --Z4'_ XZIL <br />YDS OF SOIL - 7�c6 <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />P <br />P <br />G-- snr Y as <br />Alp voa - _'L n<<uxaA*r T2F <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />I <br />TRENCH DIMENSION <br />—50- X `y X 3 <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPLING METHOD <br />x <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />L_LLABORATORY: <br />C9Gf7�/ <br />SAMPLERS NAME. LE�grr«P <br />' ,2,a, <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />14z-- <br />EH <br />4L <br />