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PUBLIC HEAD T SERVICES-ENVIRONMENTAL H"-,LTH DIVISION <br /> SITE NAME ADDRESS oo l�L CITY mop/ <br /> OWNER NAM$ OWNER PHONE # 36 7 <br /> CONTRACTOR lgl_�41CONT. PHONE # �_z 17z <br /> FIRE PERMIT <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR C� DATE y 9 TANK # 39 J 7tl <br /> R RINSED (I-4PN) METHOD �GE ��� RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE ��'r'�n1EeiE <br /> S Sc' il�E <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED ((VN) METHOD 01-0y Zi_ AMOUNT USED <br /> A <br /> P READING AT REMOVAL L. E.L. : zEt - 02 : <br /> R oZT � <br /> O <br /> COMMENTS <br /> C TANK MATERIA E L FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR OLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <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:��pQGy7i%!L_ SAMPLERS NAME:IF f ,J <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />