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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME �lh ADDRESS S ' �� C1�v `��� CITY . C� \ <br /> OWNER NAME ( OWNER PHONE ,# U <br /> CONTRACTOR l CONT. PHONE , <br /> FIRE PERMIT= 1SUC � <br /> REMOVAL_- <br /> CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR hDATE TANK # 39 � <br /> R RINSED (YJN) 7METHODz RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST .4 C/�L GC'G i,%-Z Z 2 L OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A C \' <br /> P READING AT REMOVAL L.E.L. : C) 02 : (�o � <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (gTEEf� FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POO HOLES) NG <br /> S _ :--- <br /> T PIPE MATERIAL STE -FIBFRGLAa�, OTHER) FEET <br /> PIPE CONDITION F05C�R) HOLES) <br /> DEPTH ( SOIL TYPE OBSERVATION `SAMPLE <br /> A ,z� " n � f' - - <br /> N <br /> K <br /> S EXCAVATION SIZE XX _ YDS OF SOIL T <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE ,# <br /> P P <br /> L I <br /> I P <br /> N E Cdo - 3E <br /> G <br /> TRENCH DIMENSION c-1 A_' X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> -7 <br /> CLOSURE IN PLACE 1 MIXTURE: VOLUME: l <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />