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PUBLIC HOITH SERVICES-ENVIRONMENTAL OALTH DIVISION <br /> SITE NAME ' 4-� 8 ADDRESS CITY <br /> OWNER NAMErOSco aah rNER PHONE ig <br /> d-44 J <br /> CONTRACTOR CONT. PHONE if <br /> FIRE PERMIT # m - <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE f��� �� TANK # 39 <br /> R RINSED (Y/N) METH 19 �G RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED YON) METHOD b � Lam_ AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : /� t'L, 2i <br /> 0 02 - 2 a <br /> R COMMENTS * <br /> C TANK MATERIAL (STEEL, FI EFtG SS , OPHE$) <br /> 0 7 ri ,K[-CJt 2�lL. �p[L i 11 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A <br /> N � , � 41 <br /> K « - <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <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 $ HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: e-r Ry,410 <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />