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PUBLIC HEAiLE SERVICES-ENVIRONMENTAL hi :LLTH DIVISION <br /> SITE NAME _ ADDRESS �l �� CITY /F�fes, <br /> OWNER NAMEez OWNER PHONE .4 (2 4� 655q <br /> .� <br /> CONTRACTOR CONT. PHONE , 5lj �- <br /> FIRE PERMIT <br /> REMOVAL__ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE //!f f& TANK jO 39 �35 <br /> R RINSED GIN) METHOD-r-S RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y ) METHOD AMOUNT USED l L <br /> A <br /> P READING AT REMOVAL L.E.L. : C'�a 02: �C <br /> 0 <br /> R COMMENTS <br /> Jkla <br /> C TANK MATERIAL TE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAL STEEL, FIBERGLASS, OTHER) 0 FEET <br /> PIPE CONDITION (GOOD, ER, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T < ` <br /> A � <br /> N <br /> K <br /> S EXCAVATION SIZE X XYDS 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 MIXTURE: TVOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />