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PUBLIC HEALTH SERVICES-ZN=ONMENTAL ATH DIVISION <br /> SITE NAME p ' iaf�� I ADDRESS 131 !� Q / I CITY <br /> OWNER NAME (OWNER PHONE P `) <br /> O� <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT r <br /> 11 REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 1 DATE TAN- r 3 9 <br /> R RINSED Y/N) LTTHOD I RI2TSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E 11 MANIFEST OR OTT ' <br /> V VAPORS PURGED((Y N) I METHOD �_ I AMOUNT USED / O. <br /> A cJ <br /> P _READING AT REMOVAL L.Z. O 102: f. 0. v <br /> 0 0� <br /> R COMMENTS <br /> C TANK MATERIAL S FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD D00 HOLES) ViSf <br /> S S <br /> T PIPE MATERIAL STEL FT_BZRGLASS, O ) Ic FEET <br /> PIPE CONDITION (GOOD, OOR HOLES) r U sleac <br /> DEPTH ( SOH, TYPE ( OBSERVATION ISAMPLE s <br /> N uI <br /> E I I <br /> I I <br /> SA EXCAVATION SIZE �j�X _ X YDS OF SOIL <br /> M. DEPTH ( SOIL TYPE IOBSERVATION SAMPLE. # <br /> P p <br /> L I I I <br /> I o S I S cr.4e,, I <br /> N E I I I <br /> G I I I <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: Sfoc/A I/c-( S I-' I <br /> LABORATORY: AkceajU. I SAMPT S <br /> CLOSURE IN PLACE I *f'YTIIRE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />