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SITE NAME PUBLIC HEALTH SERVICES- <br /> VIRONMENTAL 'ALTH DIVISION <br /> v il�I alb ADDRESS <br /> OWNER N I ` S S Eli, CL6G CITY <br /> AME �'S I OWNER PHONE S�cx -t <br /> CONTRACTOR I <br /> � .r�. \�i- I CONT. PHONE <br /> FIRE PERMIT <br /> r ' C J GCJJ� <br /> REMOVAL, CLOSURE IN PLA <br /> INSPECTOR \/ CE TEMPORARY CLOSURE <br /> OSS 1 o h4 DATE <br /> R TANK <br /> 39 <br /> ll: :-. , <br /> RINSED METHOD Cb'-"-- > C <br /> �, N) <br /> I �`I C <br /> �lvC �t RINSE AMOUNT Tot �I <br /> RINSATE DISPOSAL SITE �(� c; <br /> S <br /> E MANIFEST <br /> OR OTHER <br /> V VAPORS PURGEDN) METHOD <br /> A / AMOUNT USED <br /> P READINGAT R-MOVAL I <br /> O L.E.L. : (p. 02 - <br /> R COMMENTS <br /> C TANK MATERIAL <br /> � <br /> 0 ( EST- FIBERGLASS, OTHER) <br /> N 'TANK CONDITION (GOOD, 0 R, HOLES) <br /> T PIPE MATERIAL STE !vim /))u(fl� <br /> EZ,.y FIBERGLASS, OTHER) , FEET <br /> PIPE CONDITIONGOOD I <br /> ( - POO \' HOLES) I <br /> DEPTH ( SOIL TYPE IOBSERVATION <br /> T <br /> A I I SAMPLE ,# <br /> Co <br /> K I I r <br /> I � I <br /> S EXCAVATION SIZE <br /> A <br /> M DEPX X YDS OF SOIL I " <br /> DEPTH SOIL <br /> P p TYPE OBSERVATION <br /> L T I SAMPLE , <br /> P i <br /> N E I <br /> G I ; <br /> TRENCH DIMENSION s <br /> �— X X YDS OF SOIL <br /> DEPTH TO G.W. : <br /> H � FT. SAILING METHOD <br /> 2 0 HOURS SINCE DEWATERING: <br /> I 0 <br /> OTHER SAMPLE: <br /> II LABORATORY: I <br /> SAMPLERS NAME; <br /> I CLOSURE IN PLACE 3fIXTURE: <br /> VOLUME <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />