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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME Jp m R ADDRESSCITY <br /> #07_5 E. W <br /> 70 l ITJ _ <br /> OWNER N y TOWNER PHONE # / � TUY� <br /> I <br /> CONT T /'Gtp CONT. PHONE Cd BLK333FIRE PERMIT � polREMOVAL_ CLOSURE IN PLACE TEMPORARYRE <br /> INSPECTOR F/ �'S DATE(-(p-?5 TANK # 39 <br /> LNRINSED (Y/N METHOD RINSE AMOUNT <br /> RINSATE DISPOSAL SITE EN VI e pUk-MANIFEST # OR OTHER <br /> rVAPORS PURGED (Y)N) METHOD AMOUNT USED c <br /> A A.S' c // <br /> P EADING AT REMOVAL L.E.L. : 02 : <br /> O <br /> R OMMENTS <br /> C 11 TANK MATERIAL ' STEEL FIBERGLASS, OTHER) :S6D � /�_ L,p � <br /> 0 _ <br /> N TANK CONDITION (GOOD, OOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS TIi FEE <br /> PIPE CONDITION (GOOD, POOR, HOLES) c r <br /> T 11 <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE 0 <br /> P P <br /> L I <br /> I P 41 <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: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />