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PUBLIC H*TH SERVICES-ENVIRONMENTAL ONLTH DIVISION <br /> SITE NAME UJ #c7yo1 ADDRES 3a3 ' ) pots p � CITY <br /> OWNER NAMEOSC O �/haY <br /> i PHONE Q 9 T� — <br /> CONTRACTOR,J-0)LYIS CONT. PHONE <br /> FIRE PERMIT � , � • <br /> REMOVALCLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE <br /> R RINSED (Y/ I METHOD pi ht�t� r � i C e RINSE AMO <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (0/N) METHOD ; AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : n) A a, i 02 : Load, _S <br /> O <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) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> r ¢ w G c <br /> A iL� Ci <br /> N G <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 /> Ll TRENCH DIIENSION X XYDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 Of HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: Gr <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />