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PUBLIC HEA* SERVICES-ENVIRONMENTAL RTH DIVISION <br /> SITE NAME <br /> �c - ADDRESSRA// I i) CITY <br /> OWNER NAMES �'"' JOWNER PHONE eyx <br /> cam{, <br /> CONTRACTOR 111CONT. PHONE # <br /> FIRE PERMIT jf q?- IQ � �3 i 3a c W <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE f TANK # 3 9 7 -- <br /> R RINSED ( N) I METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S r N <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y } �MEHOD G� l C� AMOUNT USED 3 d� � i <br /> A <br /> P READING AT REMOVAL L.E.L. 02: <br /> O <br /> R CoMl=' S <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER} <br /> 0 p ;� <br /> N TANK CONDITION (GOO POOR, HOLES) � " 4� <br /> S ' <br /> T PIPE MAT ERIp� z `� . T Gll ASS- OT=) I FEET <br /> PIPE CONDITION (GOOD POOR), HOLES) <br /> I <br /> DEPTHSOIL TYPE OBSERVATION ( SAMPLE <br /> T I f <br /> A <br /> N � <br /> K ` I r <br /> S EXCAVATION SIZE 'X 3-C'X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE I OBSERVATION SAMPLE # <br /> P P I I <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 rl HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: O G f E A YL fiL. - <br /> LABORATORY: I S L S N <br /> I <br /> IF CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> 1 p `�. <br />