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PUBLIC HFAT,TH SERVICES-ENVIRONMENTAL 'TF.ALTH DIVISION <br /> SITE7NAMEG�v� G � <br /> -� GoTH_�'PADDRESS / /� ����j CITY <br /> OWNER NAME /� NER PHONE # (-7p 7 / �� - �,L7� <br /> CONTRACTOR A"f CONT. PHONE # / (�7 <br /> FIRE PERMIT # <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED (Y/4) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED fN) METHOD OeY AMOUNT USEDZ,,-2 <br /> A <br /> P READING AT REMOVAL L. E.L. : p p�/� 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL" ( TEEL FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, P OLES) <br /> S <br /> T PIPE MATERIAL S E , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD POOR,SOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A n OG- t��Ctz.� i icv cc w -coo <br /> N <br /> K <br /> S EXCAVATION SIZE X X'�� YDS OF SOIL .L 2 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> L� TRENCH DIMENSION X X YDS OF SOIL <br /> H DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LA LABORATORY: 'll�,�,, .�, SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />