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PUBLIC HEALTH SERVICES-EN'�RO , <br /> SITE NAME NMENTAL' 'ALTH DIVISION <br /> ADDRESS �? , <br /> OWNER NAME 7 �c�(�, CITY <br /> �qll}�S ~- Sj� OWNER PHONE z I SiUc�-r-� ,\ <br /> CON'T'RACTOR <br /> p <br /> S� L "I_ JCONT- PHONE <br /> -4�I - (c.337- <br /> FIRE PERMIT r c s GG, - <br /> REMOVAL, X CLOSURE TN PLACE <br /> INSPECTOR <br /> TFC ORRY CLOSURE <br /> OSI okc- DATE j j_� TANK 39 <br /> R RINSED ( N <br /> I METHOD <br /> RINSE <br /> N RINSATE DISPOSAL, SITE AMOUNT <br /> S UUc _.� <br /> E MANIFEST <br /> OR OTS <br /> V VAPORS PURGED ) METHOD <br /> A ��' e�1 AMOUNT USED <br /> P READING AT REMOVAL I <br /> O L.E.L. : 02 : <br /> R COMP-ENTS <br /> C TANK MATERIAL TE <br /> O FIBERGLASS, OBER) <br /> N TANK CONDITION (GOOD p <br /> S , OUR, HOLES) <br /> �-� �'�C�� <br /> T PIPE MATERIAL TEE <br /> FIBERGLASS, OTHER) ,` FEET <br /> PIPE CONDITIONGOOD � I <br /> ( PSR' HOLES) � <br /> DEPTH ( SOIL TYPE ( OBSERVATION <br /> A I I SAMPLE , <br /> N I <br /> IN <br /> K � - <br /> S <br /> EXCAVATION SIZE <br /> A — X — XYDS OF SOIL <br /> M DEPTH ( SOIL TYPE OBSERVATION <br /> P PSAMPLE , <br /> L p I I - J ley <br /> I I C � - <br /> N E <br /> G 3 <br /> I { <br /> TRENCH DIMENSION X ; <br /> X YDS OF SOIL <br /> DEPTH TO G.W. :�_ FT. <br /> H SAMPLING METHOD <br /> 0 <br /> 2 " HOURS SINCE DEWATEING:R <br /> I # <br /> OTHER SAMPLE: <br /> ILABORATORY: I <br /> I SAMPLERS NAME: # <br /> CLOSURE IN PLACE I MIXTURE: <br /> IVOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />