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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME r ` ````1d ,. ADDRESS ) v c C� cl CITY <br /> OWNER PHONE <br /> OWNER NAME C F 0-p <br /> CONTRACTOR » }°' CONT. PHONE i <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK $ 39 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <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 MATERIALSTEELBERGLAS , OTHER) $ FEET <br /> PIPE CONDITION (GOOD, POOR,; HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE af <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P � ., <br /> 0 <br /> L I s,id C 7 <br /> in. '1c:-a -_ -_ -.-�.,. -'r„c�citisc'-- <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X C YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> .LOSURE IN PLACE I MIXTURE: VOLUME: <br /> 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />