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PUBLIC�EALTH SERVICES-ENVIRONI�=.*4ftW HEALTH DIVISION <br /> SITE NAME tit�� ADDRESS �44C5 �� ~ CITY �Co1 <br /> OWNER NAME ��C��SCY� V� OWNER PHONE <br /> CONTRACTOR �,� . CONT. PHONE <br /> FIRE PERMIT ,: I <br /> REMOVAL �< CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �1 1 _ DATE` /Cj /G TANK 39 1.1 �S -�Gj <br /> R RINSED (�Y ,N) I I�`rHOD � s��1e l`t��SL RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIF EST P C. L2D ..S'14 Cq OR OTHER <br /> V VAPORS PURGED N) METHO07��,- `C� AMOUNT 'USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> O <br /> R COM.MEmTTS <br /> C T_XNX MATERIAL *E=�, FIBERGLASS, OTSER) <br /> 0 <br /> NTANK CONDITION (GOOD,(90R' HOLES) <br /> i S �T <br /> T PIPE ifATERIAL TEEL ' F 23ERGLASS, OTHER) s FE�='T <br /> PIPE CONDITION (GOOD, OORJ HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE if <br /> A13 I 1 �- ��I l C� .�C it-,r Cr" <br /> N i <br /> I <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 /> G <br /> TRENCH OMMIMISION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2HOURS SINCE DEWATERING: <br /> 0 <br /> LOTHER SAMPLZ: <br /> ' LABORATORY: SAMPLr"RS NAME: <br /> LCLOSURE IV PLACE MIXTURE: VOLM4E: <br /> EH 23-4043 (REV 2/23/94) PROVIDE SITE MAP <br />