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PUBLIC HERS.+` SERVICES-ENVIRONMENTAL H ALT#-, ll1v1D-.vtr / o /� <br /> CITY S3 <br /> SITS .NAME L N v ADDRESS �� iio .�� 7�� c u. <br /> OWNER NAME i OWNER PHONE J4 ��- <br /> CONTRA T� a Al/ I CONT. PHONE r <br /> FIRE PERMIT <br /> REMOVALCLOSURE IN PLACE TEMPORARY CLOSURE <br /> r� K -4 <br /> INSPECTORG,/� �, �!.;.� DATE /'��' TAN <br /> I RINSE AMOUNT� - <br /> R RINSED (Y% ) 'THOD 7p71/ <br /> I <br /> N RINSATE DISPOSAL S=— <br /> S OR OTHER <br /> E MANIFEST _ -7- <br /> 1 i METHOD i��Q v _.L-- �- AMOUNT IISID Q <br /> ILL <br /> V VAPORS PURGED (Yy/N) <br /> A f 02: <br /> P RF._ADING AT REMOVAL L.E.L. : <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL I sTmzm' FIBERGLASS, OTHER) oaQ <br /> 0 POOR, HOLES) <br /> N TANK CONDITION GOC , <br /> S <br /> T PIPE MATERIAL (ST=,, FIBERGLASS; OTHER) }I � FEET � Gf � �O/��E� <br /> PIPE CONDITION((GOODPOOR, HOLES) <br /> OBSERVATION <br /> SAMPLE <br /> DEPTH SOIL T`r'� <br /> o owl I <br /> EXCAVATION SIZE X X _ � `SDS OF SOIL 3 5 <br /> S , <br /> AOBSERVATION SAMPLE s <br /> M DEPTH SOIL TYPE <br /> P P i ti rc Ro Irl. S <br /> L I _ ,t�.V;�. I <br /> I P . <br /> N E <br /> G X X YDS OF SOIL <br /> . TRENCH DSMENSION =� <br /> DEPTH TO G.W. :_ FT. SAMPLING METHOD <br /> x <br /> 2 , HOURS SINCE DEWATERING: <br /> 0 -tILtJ� �L <br /> OTHER SAMPLE: '^ r <br /> TORY: SAMPLERS NAME. � <br /> T,ABORA � �� �. F�� <br /> CLOSURE IN PLACE MIXTURE: <br /> VOLUME: <br /> EH 23-0043 (REV 2/23/54) PROVIDE SITE MAP <br />