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PUBLIC ATH SERV ICES—M IRONMENTAL�ALTH DIVISION <br /> F <br /> E 14U 1ADDRESS ' L' �� ` CITY 'yjAME POi'b OWNER PHONETOR S CONT. PHONE <br /> RMIT �g'' Qj o <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR'S 41- <br /> �-Q' S DATE/` I�' TANK 3 3 <br /> R RINSED Y N} I METHOD "asoIry-c RINSE AMOUNT 3�spa <br /> Iq &h fi; a..fV o" '+ <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER ,I <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> P READING AT REMOVAL 1 L.E.L. : � � 02: <br /> O <br /> R COMMENTS li <br /> C TANK MATERIAL FIBERGLASS,FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, OOR HOLES) ! NU <br /> S <br /> T PIPE MATERIAL STS' FIBERGLASS, OTHER) ji;fFEZT <br /> PIPE CONDITION (GOOD, OOR HOLES) I3KSfe , <br /> DEPTH ( SOIL TYPE OBSERVATION I{ SAMPLE T <br /> T I <br /> A rj I <br /> R q I <br /> S EXCAVATION SIZE X XiYDS� OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION ;F SAMPLE r <br /> 3i <br /> P P ,{ <br /> L I k ifi <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X ij YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 HOURS SINCE DEWATERING: s <br /> iII <br /> ii <br /> 0LL <br /> I <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> ,f a <br /> YCLOSURE N PLACE � MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />