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PUBLIC HEA--7 SERVICES-ENVIRONMENTAL F ,TH DIVISION <br /> SITE NAME � SfC&C ADDRESS �3(s _ / �w ' CITY <br /> OWNER NAME `�l Q l l OWNER PHONE # zU <br /> r <br /> CONTRACTOR CONT. PHONE <br /> SSU <br /> FIRE PERMIT <br /> REMOVAL �C CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE �� S TANK ,# 39 - <br /> R RINSED (Y N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E 11MANIFEST # 9 2 U �� OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD 30 Ob,z),m-t(C-c-poop `' AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 3 <br /> li O <br />`) R COMMENTS <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> O - <br /> N TANK CONDITION GOO POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) Fis <br /> FEET <br /> PIPE CONDITION (GOOD,( POOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> N <br /> K ,v x VL <br /> S EXCAVATION SIZE X 3Q X _ YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I �- `- <br /> I Pcw- <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : �>SO FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> -T <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> ` 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />