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lAll <br /> PUBLICHr.AL2'OSERVICES—ENVIRONMENTAL HEA14g DIVISION <br /> SITE NAME s H. S ADDRESS ,-�po"A <br /> �T fJ <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR -rh r e CONT, PHONE # <br /> FIRE PERMIT # <br /> REMOVAL 4 CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR k2 e-- DATE ,�,�' GP TANK # 39 1 <br /> R RINSED ( N) I METHOD Yy�L � �, RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> AV VAPORS PURGED Y N) METHOD - - —TAMOUNT USED Q <br /> P READING AT REMOVAL L.E.L. : 02: �. <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOO POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T DEPTH I SOIL TYPE OBSERVATION ( SAMPLE ;€ <br /> N I <br /> K I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ' SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N P <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> fi <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: n ` <br /> LABORATORY: &Q,p � -k ( SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />