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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME/�/ <br />ADDRESS gpV /G v/GTi� <br />CITY Lvpr <br />OWNER <br />OWNER PHONE # g _ L l7L <br />CONTRACTOR / p G <br />CONT. PHONE <br />yfj✓Er'7 <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR � <br />DATE /G�i 9 _ TANK # 39 -7 2' <br />R <br />RINSED(Q%�1i) METHOD <br />RINSE �� RINSE AMOUNT 3 <br />I <br />N <br />S <br />RINSATE DISPOSAL SITE SFr <br />E <br />MANIFEST OR OTHER <br />V <br />VAPORS PURGED WN) <br />METHOD AMOUNT USEDe <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: 02: <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL T <br />FIBERGLASS, OTHER) �. <br />0 <br />N <br />TANK CONDITION (GOOD, <br />HOLES) <br />S <br />T <br />PIPE MATERIAL TE , <br />FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />0O 1 HOLES) <br />FL <br />T <br />DEPTH SOIL TYPE <br />OBSERVATIONa v j � Fes, ,i = vs'B •b- SAMPLE # <br />K <br />S <br />EXCAVATION SIZE ^e0 � X -Zl/- X ^--2 <br />YDS OF SOIL ^3ob <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />P <br />P <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION <br />, <br />^ 3o X ✓ X 3 <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPLING METHOD <br />H <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />