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PUBLIC HEALTH SERVICES—ENVIRONMENTAL HEIALTH DIVISION 1—o, <br /> , ?j <br /> s zT L AME S o o `ADDRESS Lo���-C� 1- e L �ITY <br /> OWNER f N I OWNER PHONE /0 ?j --- l <br /> CONTRACT?? — CONT. PHONE _ y'�3- y017, <br /> FIRE PERMIT r /,JA <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR -7GI LANK 3 9 <br /> R RINSED (Y/N� <br /> SOD A- RINSE AMOUNT <br /> I , /� <br /> N RINSATE DISPOSAL SITE /"'H-�A ` Z <br /> S OR OTHER <br /> E MANIFEST 24 <br /> V VAPORS PURGED ( /N) IMETHOD �� \� AMOUNT USED Q <br /> A v <br /> P READING AT REMOVAL L.E.L. : O 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (S FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD POOR, HOLES) z— <br /> S FIBERGLASS, OTHER) r- FEET <br /> T PIPE MATERI_ L <br /> PIPE CONDITION (GOON POOR, HOLES) � �., P -'r 1,U l� <br /> DEPTH SOIL TY-2E <br /> OBSERVATION ( SAMPLE r <br /> T �G 5, 1= � , v . r ✓ <br /> w A), ►amu o <br /> o <br /> K (/- / cYct.r y 10 <br /> S , EXCAVATION SIZE X X YDS OF SOIL <br /> A SAMPLE <br /> m EDEPTHiSOIL TYPE OBSERVATION <br /> P P I <br /> L I <br /> i <br /> I P � <br /> N E <br /> G X YDS OF SOIL <br /> DIMENSION X <br /> DEPTH TO G.W. : � FT. " SAMPLING METHOD <br /> H <br /> 2 J4 HOURS SINCE DEWATERING: <br /> 0 OTHER SAMPLE: A 2+n N <br /> LABORATORY:(l(&lSAMPLERS NAME <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> ER 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />