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PUBLIC 'r'rEUTS SERVICES-ENV-IRONMENT31L EZ rTH DIVISION <br />SITE NAME Ke S <br />I ADDRESS 76 / E CITY S7 40 cr-hl)� <br />OWNER NAM" 'V a <br />i OWNER PHONE <br />j <br />CONTRACTOR I SiOVIe <br />I CONT. PHONE <br />F IR. E P 7—"R MlT T <br />I - <br />1;"T --Ko VAI,_Y-- CLOSURE IN PLACE <br />TEL=-CRARY CLOSURE <br />INSPECTOR�rI <br />DATE <br />TANK if 39 <br />C- <br />R <br />I <br />RL`TSED (Y/N) I -T=ROD <br />RINSE AMOUNT <br />N <br />S <br />=SATE DISPOSAL SITE <br />.. <br />XANI='EST r <br />OR OTRER <br />V <br />A <br />VAPORS PURGED (Y/N) <br />'METHOD <br />(AMOUNT' USED <br />P <br />0 <br />READING AT RMI -OVAL <br />I L.E.L.: <br />102: <br />� <br />I <br />R <br />CCZ^-.. E S <br />IC I <br />0 <br />TANX-NaTERLXL ( STEL, <br />FIBERGLASS, OTB ) <br />I <br />N <br />S <br />T_NK CONDITION (GOOD, <br />POOR, HOLES) <br />T <br />PIPE (S T E --r , <br />FIBERGLASS, , OT=) I -Z FrET <br />i <br />PTPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />T <br />N <br />j DEPTH ISOIL, TYPE <br />I <br />I OBSERVATION <br />l SAMPLE T <br />I I I /) <br />- <br />I K <br />I EXCAVa,TION SIZE X X (YDS OF SOL <br />A <br />M <br />P <br />L <br />I <br />G <br />p <br />I <br />P <br />(DEPTH SOIL TYPE <br />(OBSERVATION <br />(SAMPLE r <br />I I I <br />I I <br />TR.- 7CH DIIENSION X X I YDS OF SOIL <br />�I <br />2 <br />0 <br />DET= TO G.A.: FT. <br />SAMPLING METHOD <br />HOURS SINCE D-zWA^'ER_TNG : <br />OTBwR SAMPLE: <br />LABORATORY: I <br />SAMPLERS NAME: <br />F -CLOSURE IN PLACE M;xTL�E <br />: <br />I VOLIIM:..: <br />HE 23-0043 (REV 2/23/94) PROVIDE SITE NEP <br />