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PUBLIC HEA'7H SERVICES-ENVIRONMENTAL F^AI TH DIVISION <br /> SITE NAME a ADDRESS �p yG� CITY G�4 <br /> OWNER NAMEF OWNER PHONE <br /> CONTRACTORCONT. PHONE 67 <br /> FIRE PERMIT ,� <br /> REMOVAL�� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR E�L -vE DATE / y� TAMC 39 / 7c}[j 5, <br /> R RINSED (Y/N) HETHOD /rPGE G RINSE AMCUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> MANIFEST <br /> E ILOBI�41,D OR OTHER <br /> JRV VAPORS PURGED (Y/N) METHOD �� Y 'L` AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E. L. : 02 : U <br /> O <br /> COMMENTS <br /> C TAMC MATERIALSTE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION. (GOOD, OOR, )OLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER)7; FEET <br /> PIPE CONDITION (GOOP2 <br /> P HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A <br /> N o c�of' Ivor c5 <br /> K <br /> S EXCAVATION SIZE _ft1G X 3y X t7 r YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME:�E��� v <br /> CLOSURE IN PLACE HIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />