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PUBLIC HEA .,H SERVICES-ENVIRONMENTAL h_�.LTH DIVISION <br /> SITE NAME ADDRESS q CITY <br /> OWNER NAME (OWNER PHONE ,# <br /> 62= <br /> CONTRACTOR CONT. PHONE , <br /> C_31E) a� <br /> FIRE PERMIT at <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 1 39 <br /> R RINSED (Y ) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S C <br /> E MANIFEST OR OTHER 0G <br /> V VAPORS PURGED Y� ) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : ® of 02: C � d�n <br /> O �' <br /> R COMMENTS C- + o , <br /> C TANK MATERI (STE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, HOLES) <br /> S <br /> T PIPE MATERIAL (STE IBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> T <br /> 'S.)A i <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 XJA� <br /> L I <br /> I P <br /> N E <br /> Ll G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> _7DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 , HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> _T <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />