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PUBLIC-l=TH SERVICES—ENVIRONMEN%, <br /> HEALTH DIVISION <br /> SITE NAME ADDRESS nn c CIT`I � <br /> ��C:410r`1 <br /> OWNER NAME l�arn�5 ne�ckv I OWNER PHONE <br /> CONTRACTOR �'�a�tz�'� CONT. PHONE <br /> FIRE PERMIT � <br /> REMOVAL X CLOSURE IN PLACE TE��ORARv CLOSURE <br /> INSPECTOR y�5h � � DATE %G f TANK at 3 9 (.44 t S CJ� <br /> R RINSED (?JN) METHOD _ �_ RINSE AMOUNT �C(� <br /> I <br /> N RINSATE DISPOSAL SITS <br /> S <br /> E MANIFEST s Ci64 Z&j 4 C)�( OR OTHER <br /> VVAPORS PURGED &/N) METHOD � I G� AMOUNT USED <br /> A <br /> J� <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R cola=f <br /> C TANK MATEIRMU TEFL FIBERGLASS, OTHER) ! <br /> r�C C��C �`CU'L�t" j'1C`i e� <br /> o � , <br /> N TANK CONDITION (GOOD, POQR; HOLES) I <br /> ! <br /> L1T11PIPE MAT�IAL ( TEEL FIBERGLASS, OTHE )PIPE CONDITION (GOOD, POOR SALES) `�� ,,t'C��G l <br /> DEPTH SOLI, TYPE OBSERVATION SAMPLE <br /> IT i! <br /> n � , U SIC ^ <br /> ' cJI,ti H <br /> E I I <br /> I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SO= TYPE OBSERVATION SAMPLE � <br /> P P C. a lccl w,, lVn , - vx C c^ I <br /> L I <br /> I P <br /> N E f ' `i n5n L1 r+G^r t. <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPL22TG METHOD <br /> H <br /> 2 ` HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SADOLZMS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> Eli 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />