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PUBLIC HI <br /> .�!H SERVICES-ENVIRONMENTAL`, LTH DIVISION <br /> SITE NAME - c- ADDRESS �D` CITY -T` <br /> OWNER NAME ( OWNER PHONE <br /> CONTRACTORCONT. PHONE II <br /> FIRE PERMIT Jr-1 <br /> t REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR,,- DATE �o��oa TANK �`��• 39 '- O\D�303 <br /> Sl��� <br /> R RINSED Y/N) MEI'AOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S . <br /> E MANIFEST 24 OR OTHER <br /> V VAPORS PURGED 0/N) METHOD �{ I AMOUNT USED .4 <br /> A <br />{ P READING AT REMOVAL L.E.L. : i 02 : <br /> O <br /> R COMMENTS <br /> I! , <br /> C TANK MATERIAL (S EEL FIBERGLASS, OTHER) j tjw f QLhsS .r <br /> O <br /> N TANK CONDITIONGOO , POOR, HOLES) <br /> . S � <br /> T PIPE MATERIAL (STEEL, iiiiiGLAS , OTHER) l!' FEET <br /> I 1 <br /> PIPE CONDITION GOO POOR, HOLES) :I <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T � <br /> A <br /> N <br /> S EXCAVATION SIZE _� X \"1 X �� YDS OF SOIL <br /> A , y o Ip <br /> M DEPTH SOIL TYPE OBSERVATION J " SAMPLE <br /> P P <br /> L I tit 4r 09�¢ - two <br /> N <br /> G &W-7 OsD,(— , SIAG <br /> TRENCH DIMENSION 1 X Xj� 1 YDS OF SOIL <br /> 3 <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 ` HOURS SINCE DEWATERING: �{ <br /> 0 <br /> OTHER SAMPLE: I <br /> LABORATORY: y G SAMPLERS NAME:LL <br /> ,F <br /> CLOSURE IN PLACE MIXTURE: !VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> t <br />