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PUBLIC F^kLTH SERVICES-ENVIRONMENTAT HEALTH DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR N CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARYl�7gSURE <br /> INSPECTOR DATE 9L TANK # 39 <br /> R RINSED METHOD > RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED N) METHOD AMOUNT USED 1y�� <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : 36� <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> O p e <br /> N TANK CONDITION GOOD, POOR, HOLES) �oQp� �wo+CT�I <br /> S <br /> T PIPE MATERIAL (STEEL, IBERGLASS OTHER) # FEET <br /> PIPE CONDITION G00 , POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A 1 bl56ptptzbLt b Y <br /> K /h- = Aae 3 i9 <br /> g, 2 t [S�e6D <br /> S EXCAVATION SIZE CJS X _jL X YDS OF SOIL f � <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P 2- LT EJ SYrto�/6 C o <br /> L I <br /> I P <br /> N E <br /> G TRENCH DIMENSION 3,6j X 8r X '� YDS OF SOIL ? <br /> DEPTH TO G.W. : I32 FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />