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PUBLIC HEAl,�H SERVICES-ZNV'IRONMENTTAL HEALTH DIVISION <br />SITE NAM Ki- S 64S` %i�OC_�DRESS <br />-76 G , 64ti-f- I CITY <br />OWNER NAME <br />i OWNER PHONE 1 <br />CONTRACTOR <br />11 MANIFEST <br />(CONT. PHONE <br />V <br />VAPORS PURGED (Y/N) <br />R_T'MOVALX_ CLOSURE <br />IiT PLACE TE ORARY CLOSLRE <br />INSPECTOR' <br />DATE '} 13 TANK t 39 <br />R <br />I <br />Rw-`TSED (Y/N)v V_E`=OD I RINSE AMOUNT <br />N <br />S <br />RL'dSATE DISPOSAL SITE <br />E <br />11 MANIFEST <br />OR OTS. r.R <br />V <br />VAPORS PURGED (Y/N) <br />ME HODI AMOUNT USED I <br />A <br />P <br />0 <br />=LDING AT REMOVAL <br />i L.E.L.: 102: <br />R <br />COMMENTS <br />C <br />0 <br />I T.2 NZ M�TERTAL ( STEEL, <br />FIBERGLASS , OTS) <br />I <br />N <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />S(STE-M <br />, <br />FIBERGLASS , 0'-T=--) I ' "" T <br />Pis CONDITION (GOOD, <br />POOR, HOLES) t <br />IL <br />S <br />T <br />I DEPTH (SOIL TYPE <br />I <br />`OBSERVATION <br />ISAMpLE T j <br />I <br />I <br />3 LL I <br />i I <br />I EXCAVATION S1Ji. <br />o X I YDS OF SOIL <br />I <br />A <br />M_ <br />L <br />_ <br />I <br />G <br />(DEPTH <br />? <br />ISOIL TYPE <br />JOBSERVATION (SAMPLE r <br />I I I <br />I <br />I i <br />TRENCH DI=SION <br />X X (YDS OF SOIL <br />LL <br />I <br />2 <br />0 <br />DEPTH TO G.W. FT. SAMPLING METHOD <br />r HOURS SINCE DEWA—MER_.NG: I <br />: ."R SAMPLE: <br />LA30RATORY : I SAMPTI"ERS NAME: <br />IF C.T CS=U. IN PLACE I H <br />XTURE: <br />I VOLUME: <br />.y. 23-0043 (REV 2/23/94) <br />PROVIDE SITE MAP <br />