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PUBLIC a^nr,WEgprCES—ENVI20NM_ENTAL HEALTH DIVISION <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE- ?SAP <br />ADDRESS a fWk C'Ty M (f} <br />SITE NAME L I <br />A 7 0 ,N)M& <br />0WNER NAME ' <br />10WNER PHONE r <br />CONTRACTOR TFtlTbi\J CONSIR-MIt <br />e oN'-" • PHONE <br />FIRE P-. T T 0 n- b--� <br />Pr E TEMPO C r OSURE <br />REMOVAL � Q.OSDRE T`7 .AC.. <br />DATZ Q2 f��DC TANK # 39 <br />INSPECTOR <br />RSNSED (Y/�j :SHOD <br />RINSE AMOUNT <br />j R <br />I <br />N <br />RIPiSATE DISPOGnr• SITE <br />S <br />E <br />MANIFEST r OR 0I_ER <br />T�'MORS PDRGED (Y/N) �ir"THOD <br />I <br />I ? SOIINT USED <br />� <br />V <br />P <br />READING AT REMOVAL L.E.L.: <br />E <br />02 <br />0 <br />R <br />COi�NTS <br />TA,\T FTS-RGL2.SS , OTHER) <br />C I <br />yITAl`1?K <br />CONDITION (GOOD, POOR, HOLES) <br />S <br />m <br />_oI�E MATERT�I. (STz S, ?MZRGI.ASS, OTHER) <br />I <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />DEPTH I SO-:.. TYPE I OBSMT77 ION I SAMPLE r <br />n <br />! 1 i <br />! <br />Ir <br />!t SI Loafr6 � o I <br />J I II tl <br />rl u <br />bs' I <br />SIZE Y x YDS OF SOIL <br />S <br />EXCAV2,TION <br />M <br />DOTH SO - PIOBSN <br />II <br />I P <br />P <br />11V9 <br />u )IJO oo I v <br />LT <br />I It I <br />T <br />P <br />II <br />N <br />. <br />51I, I n 11 I 11 <br />G <br />113 * V g Z� % I I YDS OF SOIL <br />TQ...iti'NCH DZwE`i75ION <br />DEPTH TO G.N.: FT. I SADLL1-7G METHOD <br />i <br />H <br />2 <br />r fiODRS ST?7CE r)EWA`�'ET�-7 TG: <br />0 <br />OTHER SAMPLE: NlF) <br />LABORATORY: j-jD( IZON (--,N[1 11N)CzJJ ��LSAM-La"RS NAL: C21A 6) Q7 <br />LN PLd� IMRE VOLIIME: <br />CLOSZTRE <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE- ?SAP <br />