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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME h ADDRESS i 5 AL)f JCITY44?j� <br /> OWNER NAME �� DSS OWNER PHONE <br /> CONTRACTOR CONT. PHONE # 179L „V414 <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE 8 TANK # 39 <br /> R RINSED Y N) METHOD RINSE AMOUNT <br /> I <br /> J[N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> TRAV VAPORS PURGED N) METHOD AMOUNT USED <br /> P READING AT REMOVAL L.E.L. : O2: �Y <br /> 0 <br /> COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLAS <br /> O , 0 r,� <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATEPLTALLSTAIBERGLASS, OTHER) ,iE FEET r4- <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A <br /> N I <br /> K <br /> S EXCAVATION SIZE -�-4 L X ll w X YDS OF SOIL <br /> A <br /> M DEPTH I 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 /> L0DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 1 HOURS SINCE DEWATERING: <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />