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PUBLIC HEALTH SERVICES-ENVIRONMENT)` HEALTH DIVISION <br /> SITE NAMEo u ADDRESS (`!�/ C-lam ��( CITY 5 /� <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL AC CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 !$D6 P06�/�*1 <br /> R RINSED Y N) METHOD RINSE AMOUNT 3DD <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED ()N) METHOD AMOUNT USED ZS�� <br /> A <br /> P READING AT REMOVAL L. E.L. : 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, IBERGLASS OTHER) # FEET 2 / <br /> PIPE CONDITION GOOD POOR, HOLES)/gyp QP� A a" <br /> DEPTH SOIL TYPE OBSERVATION — ���"`� '� SAMPLE # <br /> T SSD 7-5z/'W' f5'r <br /> A <br /> N t R T55 P <br /> K UG of <br /> S EXCAVATION SIZE X X /Z YDS OF SOIL � b+ <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I ¢ <br /> I P <br /> N E ✓ NtO t <br /> G TRENCH DIMENSION YDS OF SOIL <br /> DEPTH TO G.W. : ( 37 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 />