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PUBLIC HE&_fH SERVICES -ENVIRONMENTAL i,_.:.ALTH DIVISION <br />SITE NAME SU S D <br />ADDRESS <br />OWNER NAME SLL S U <br />OWNER PHONE # <br />CONTRACTOR RA- tn L s <br />CONT. PHONE # <br />FIRE PERMIT # <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR '�i �'� �`' i S <br />DATE ) -3-q'f TANK # 39 6" q 7 <br />R <br />RINSED (Y/D METHOD • RINSE d <br />I <br />N <br />RINSATE DISPOSAL SITE <br />ND r Fi S A- �e , <br />S <br />E JIMANIFEST <br /># <br />OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED ( Y N) <br />READING AT REMOVAL <br />COMMENTS <br />METHOD �� C� AMOUNT USED J�tC IbS <br />L . E . L .: 02: 3 . 4 `°z <br />C <br />TANK MATERIAL ( TEEL, <br />)FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION OOD, <br />POOR, HOLES)9h� <br />S <br />T <br />PIPE TERIAl< STEEL <br />FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) Wvj�_ <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />red dis L b <br />EXCAVATION SIZE <br />X X <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />Iry i <br />TRENCH DIMENSION <br />X X <br />YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: SAMPLERS NAME: Qe1 <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />