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PUBLIC,,.,EALTH SERVICES-ENVTRONMEM HEALTH DIVISION <br /> SITE NAME �,L ADDRESS l [ t C ��t CITY FS�Lll <br /> OWNER NAME 1 1Cv��C�S C-�1GtLk0 OWNER PHONE <br /> CONTRACTORn � CONT. PHONE <br /> FIRE PERMIT ir" <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR .�� i DATE TANK # 39 }J4 <br /> R RINSED N) I METHOD iV\ RINSE AMOUNT(� <br /> I t <br /> N RINSATE DISPOSAL SITE C vti1L�,v U <br /> E MANIFEST r q LO(D '� d`1 OR O'T'HER <br /> V VAPORS PURGED(a) METHOD AMOUNT USED ZZE (� <br /> A l-- <br /> P READING AT REMOVAL I L.E.L. 1 02: / ate l <br /> O <br /> R COM.mTTS <br /> C TANK MATERIAL STEED, FIBERGLASS, OTHER) <br /> 0 <br /> N T_ANR CONDITION (GOOD, POOR .. HOLES) tir�r -tort <br /> S <br /> T PIPE M.ATEDI L STEED � FIBERGLASS, OTHER) T FEET <br /> PIPE CONDITION (GOOD, Co, HOLES) <br /> DEPTH ( SOIL TYPE ' OBSZRVATION SAMPLE <br /> T l I I t C�C�' <br /> A <br /> � I I <br /> S ION SIZE — X — X YDS OF SOIL <br /> " A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> P P <br /> L I I <br /> I P I I <br /> N E I I <br /> G <br /> TRENCH OnMISION X X YDS OF SOIL <br /> DEP'T'H TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> JL LABCRATORY: SAMPLERS NAME <br /> CLOSURE IN PLACE I M=X T VRE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />