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PUBLIC HEPTTH SERVICES-ENVIRONMENTAL VALTH DIVISION <br /> SITE NAME/ -__[ADDRESS <br /> p yG74�Nf,,yeQ CITY G�q � <br /> OWNER NAMES OWNER PHONE <br /> CONTRACTOR 65;Z�z— EAl CONT. PHONE <br /> FIRE PERMIT # <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORE�� -vim DATE ��y� TANK 39 f 7c _S. <br /> R RINSED a/N) METHOD pG� �i��cr RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE 20 (6' <br /> S <br /> E MANIFEST # t{a,p� ��o OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD Pit S F AMOUNT USED <br /> A <br /> P READING AT REMOVAL L. E.L. : 02 : O <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIALFIB GLASS, OTHER) <br /> O <br /> N TANK CONDITION.. (GOOD, PO HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) I FEET <br /> PIPE CONDITION (GOOD, OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A / Opnk Say- or sGc[-O Tro cS <br /> N <br /> K <br /> S EXCAVATION SIZE �t�� X ^30-X / 7' 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: �€�F��� <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />