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PUBLIC HE.A- H SERVICES-ENVIRONMENTAL H' _ LTH DIVISION <br /> SITE NAME Ga J�h� ADDRESS (fpp , CITY G� <br /> OWNER NAME _ OWNER PHONE <br /> CONTRACTOR ICONT. PHONE <br /> FIRE PERMIT # 14 9� <br /> REMOVAL_ CLOSURE ---'i PLACE TEMPORARY CLOSURE <br /> INSPECTOR „, �1/ DATE p��f y TANK # 395os�/6 <br /> R RINSED /� YN) Y_=HOD SND dJ�� RINSE AMOUNT <br /> N RINSATEvvDISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD Pza-Y AMOUNT USED o 4f <br /> A <br /> P READING AT REMOVAL I L.E.L. : _ C , 02 : _ <br /> O <br /> R COMMENTS G�I�GI�o <br /> C TANK MATERIAL ( STEEL, .fIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOO POOR, OLES) <br /> S <br /> T PIPE MATERI (STEEL, IBERGLASS, OTHER) <br /> PIPE CONDITION (GOO POOR, BOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A 0.5 Y 4-A” 1 ALSat- 06 c ! @ /0- s <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL L <br /> A 1J <br /> M DEPTH SOIL TYPE ( OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSICN X X YllS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> G�OGo6yCAL <br /> LABORATORY: SAMPLERS NAME: ���i/'z��� <br /> CLOSURE IN PLACE KiXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />