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PUBLIC HEI' B SERVICES-ENVIRONMENTAL F' LTH DIVISION <br /> SITE NAME tZ- II ADDRESS CITY <br /> OWNER NAME OWNER PHONE , e.! <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT P <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR IWDATE ( I TANK , 39 ( / <br /> R RINSED (Y ) METHOD , RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE , <br /> S <br /> E JIMANIFEST # OR OTHER ; <br /> V VAPORS PURGED �(N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENT <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GO , POOR./ HOLES) <br /> S <br /> T PIPE MATERIAL S , FIBERGLASS, OTHER) , FEET <br /> PIPE CONDITION (GOOD BOOR, _ OLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH 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 /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE 7MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />