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PUBLIC HEAILTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ' _���' � U ADDRESS �q�} pi`Gco�1` � r CITY <br /> OWNER NAMEGr �'� �i.Zr� OWNER PHONE a ` <br /> _S aIt�)Ta3-7 <br /> jz_CONTRACTOR I K CONT. PHONE .11lLf- - <br /> FIRE PERMIT ` -rA � �s /�� <br /> REMOVAL X— CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR Ufa`I- s DATE l - �7TANK of 39 �� Q D <br /> R RINSED (Y/N) METHOD / RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE j <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOV L.E.L. : 02: <br /> 0 s . <br /> R COMMENTS R IG <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS OTHER) J FEET & <br /> 1 <br /> PIPE CONDITION (GOOD00 HOLES) , r �' <br /> a. o bn O <br /> DEPTH SOIL TYPE OBSERVATION ( SAMPLE <br /> T k. # jA)est <br /> A f <br /> N �r <br /> K <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 k:—,j <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 ,.4 HOURS SINCE DEWATERING: <br /> OTHER SAMPLE: <br /> L ul��c <br /> LABORATORY: JeAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />