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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> r `r <br /> r SITE NAMJ�Lq�j /n '; AS <br /> 706 , - CITY.,Souk <br /> OWNER N roSkao (x I OWNER PHONE I Z0c7 - bS- 2,96 7 <br /> CONTRACTO S� D�� CONT. PHONE 0 <br /> FIRE PERMIT if <br /> REMOVAL CLOSURE IN PLACE TEMPO <br /> INSPECTOR �/ DATE 6�C o -� TANZf 3 9 <br /> R RINSED /N) METHOD so <br /> I <br /> N RTNSATE DISPOSAL SITE -fi <br /> S 2.x 7 p <br /> 1 <br /> E MANIFEST ,�` OR OTHER <br /> V VAPORS PURGED /N) METHOD AMOUNT USED Zs(� <br /> A <br /> P READING AT REMOVAL L.E.L_ : 02: <br /> 0 <br /> R 11-COMMENTS <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, LO0 HOLES) <br /> S <br /> T PIPE MATERIALTE , FIBERGLASS, -OTHER) r FEET <br /> PIPs' CONDITION (GOOD, POO , HOLES) <br /> DEPTH SOIL TYPE JOBSERVATION SAMPLE v <br /> T <br /> A cQor dP x.z,*J <br /> N . <br /> de <br /> S L <br /> S EXCAVATION SIZE 7,&Y X ZJ1 X � YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE if <br /> P P 774 <br /> L I { <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD ; <br /> H <br /> 2HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY , SAMPLERS NAME:e= /47,e- <br /> CLOSURE <br /> 4uCLOSURE IN PLACE MIXTURE: VOLUME: <br /> . .... <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />