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PUBLIC HEA_ -H SERVICES -ENVIRONMENTAL fi_.LTH DIVISION <br />SITE NAME 56t S f) <br />ADDRESS(� � ee �� h �� <br />CITY 's' �k <br />OWNER NAME w � _ <br />(OWNER PHONE <br />CONTRACTOR R /4 61 GS <br />CONT . PHONE , <br />FIRE PERMIT , <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR 'S �r �' r ��J` S1 <br />DATE l -3- T7 TANK r 3 9 / ��- <br />R <br />I <br />RINSED kY/ ) METHOD <br />�� S ba <br />RINSE OUNT <br />N <br />S <br />RINSATE DISPOSAL SITE (/O r Yl S /i fe <br />E <br />MANIFEST <br />OR OTHER <br />V <br />VAPORS PURGED(Y N) <br />METHOD ftp (G, <br />AMOUNT USED j 66 1 b,5 <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: ` <br />02: ` <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL STEEL) <br />FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION ( GOOD, <br />POOR, HOLES) <br />Ss► <br />5 S h G`PS c` <br />S <br />T <br />PIPEMATERIAL STE , <br />FIBERGLASS, OTHER) <br />0 <br />FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE iO <br />T <br />A <br />N <br />K <br />a. c13 <br />,( <br />S <br />EXCAVATION SIZE <br />X X <br />YDS <br />OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE ,# <br />P <br />P <br />L <br />I <br />121 <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION <br />X X <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPLING METHOD <br />H <br />2 <br />1 HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE:-�O�-�C r �e <br />LABORATORY: <br />SAMPLERS NAME: <br />IF—CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />