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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME'S/ <br />ADDRESS G�pU lG / CITY i _ADT <br />OWNER NAMF/ <br />OWNER PHONE <br />CONTRACTOR <br />i ,ems o.G <br />CONT. PHONE <br />FIRE PERMIT # v� <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />7 c/ Z <br />INSPECTOR E� l� DATE �G�r 9 _ TANK # 39 _L7 <br />R <br />I <br />RINSED Y/N) METHOD��,oGE �r RINSE AMOUNT?j7sGi <br />N <br />5 <br />RINSATE DISPOSAL SITE �EFIis 6� �Ee rc�j <br />E <br />MANIFEST OR OTHER <br />V <br />A <br />VAPORS PURGED (71M) METHOD PO -'r rG� AMOUNT USED <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />02: <br />O <br />R <br />COMMENTS <br />C <br />TANK MATERIAL FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, Ffl--, HOLES) <br />S <br />T <br />PIPE MATERIAL EEL IBERGLASS, OTHER) # FEET <br />PIPE CONDITION (GOOD, OOR "HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE` <br />c,4 e, v 5aL rSUKo1 I-rz-z-T-.,6. <br />A <br />N. Seita. drSCr.Z'gB1T� GL -7S-/6— <br />N <br />K <br />S <br />EXCAVATION SIZE X ^T1/- X ^ /Z� <br />YDS OF SOIL '3oU <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE <br />P <br />P <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION L X ^ '�f X '�` <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />x <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY } <br />A�y y scq� <br />SAMPLERS NAME: 'y�G L AcLS� <br />/zrc; tis <br />CLOSURE IN PLACE <br />I MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />