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PUBLIC HEA.10 SERVICES-ENVIRONMENTAL HF.W DIVISION <br /> SITE NAME io <br /> lw& ADDRESS A/ /-, o �pYL CITY !d c, <br /> OWNER NAME- k 1 OWNER PHONE t t <br /> CONTRACTOR ' , j d CONT. PHONE t 616 0 — �l <br /> FIRE PERMIT " 7 9— a J c� 6 <br /> =OVAL� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR y DATE , .- J 'TANK it 39 <br /> R RINSED OY N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER. <br /> V VAPORS PURGED (P/N) I METHOD r � AMOUNT USED <br /> A -T <br /> P READING AT REMOVAL L.E.L. : 02. <br /> 0 0 ` <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) Am <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T I <br /> A I� <br /> K t I I-T <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ( SOIL TYPE OBSERVATION SAMPLE <br /> P P I I <br /> L I <br /> I P I i <br /> N <br /> G <br /> TRENCH DI=SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. [SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OT= SAMPLE: I <br /> LABORATORY: SAMPLERS NAME: <br /> DCL©Si ET PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />