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SITE NAME F,. { ADDRESS 5�9D I CITY <br /> OWNER NAME rJs OWNER PHONE <br /> CONTRACTOR �/v!C CONT. PHONE <br /> FIRE PERMIT ` <br /> ,1 <br /> REMOVAL CLOSURE IN PLACE �j TEMPORARY CLOSURE <br /> INSPECTOR � <br /> DATE J� I TANK 39 <br /> R RINSEDY N) METHOD (,t9e )-r C�4 D RINSE AMODNT ^Pd <br /> I ' ` <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER p. <br /> V VAPORS PURGED (Y/N) METHOD ; AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : a `02: <br /> 0 <br /> LR I COMMENTS <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) <br /> 0 �r e <br /> N TANK CONDITION (GOOD OOR HOLES) I <br /> S <br /> T PIPE MATERI (STEEL) FIBERGLASS, OTHER) If il FEET <br /> PIPE CONDITION (GOOD, OR, OLES) ; W <br /> DEPTH SOIL TYPE OBSERVATION I SAMPLE ,€ <br /> T } <br /> N <br /> ;I ci h <br /> S EXCAVATION SIZE X X IYDS:IilOF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION :z SAMPLE f <br /> P P <br /> L I li I <br /> I P <br /> G <br /> TRENCH DIMENSION X X I YDS OF SOIL <br /> } <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H , <br /> 2 ` HOURS SINCE DEWATERING: Ij <br /> 0 s <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> M <br /> C <br /> CLOSURE IN PLACE MIXTURE-' VOLUME: <br /> i <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />