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PUBLIC FyXLTH SERVICES-ENVIRONMENTAT HEALTH DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR � �� CONT. PHONE # <br /> FIRE PERMIT i 6 _� <br /> REMOVAL CLOSURE IN PLACE TEMPORARY� CLOSURE <br /> INSPECTOR DATE '2 ;�- fG TANK # 39 - 6 -1 <br /> R RINSED METHOD RINSE AMOUNT o <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y N) METHOD AMOUNT USED -2e <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> I <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS OTHER) # FEET -:z:- 2C)' <br /> PIPE CONDITION (GOOD, POOR, HOLES) ( J „e ✓t.- 6Y�)a" <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T /D-// ' - f.a y( 7-52- -r <br /> A �- p' <br /> N p 5 � <br /> K L) <br /> S EXCAVATION SIZE 35u1X Al X [7 d YDS OF SOIL l5oJ 3 <br /> A �o <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P _ _ .Z <br /> L I pQ� <br /> I P <br /> N E � <br /> G <br /> TRENCH DIMENSION Li X <br /> -kAy 3O` YDS OF SOIL <br /> DEPTH TO G.W. : t32- 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 />