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PUBLIC HEAL'T'H SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME/h v _ ADDRESS //y S CITY <br /> OWNER NAME Al GJ• OW-NTR PHONE T /j_ rj ?j 67QZ <br /> CONTRACTOR ] nL U✓� �w,I CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IT PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 4 39 ,SO j'j p"Z O Z. <br /> R RINSEDN) I METHOD �� �z RINSE AMOUNT so �( <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED - (YJ-9) METHOD u AMOUNT USED ySv <br /> A <br /> P READING AT REMOVAL ( L.E.L. : d 02: <br /> 0 <br /> R COMMENTS CSL rJa ^ <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, _2O , HOLES) ksP <br /> S <br /> T PIPE MATERIAL FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, 00 , LES <br /> DEPTH SOIL TYPE ( OBSERVATION SAMPLE <br /> T <br /> A <br /> N S sp <br /> K rao-wQ s• s /[3 <br /> EXCAVATION SIZE 3Z.' X X YDS OF SOIL 16fO YcPs <br /> S <br /> M DEPTH SOIL TYPE OBSnRVATION SAMPLE r ' <br /> P P 3 , � i <br /> L I v .3 <br /> I P no cdor <br /> G <br /> TR..."CH DISENSION X X YDS OF SOl� <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY:, Q, aQ I SAMPLERS NAME:)(ted E/�%,. <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> r.3 23-0043 ('-REV 2/23/94) PROVIDE SITE MAP <br />