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PUBLIC HEk,,fH SERVICES—ENVIRONMENTAL hzALTH DIVISION <br />SITE NAME <br />ADDRESS �2jc�2����� <br />FITYC� <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTOR� <br />CONT. PHONE # <br />FIRE PERMIT # <br />REMOVAL '� CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR\IOC DATE TANK # 39 1()C' <br />R <br />I <br />N <br />Sr <br />E <br />RINSED(( ) METHODZU RINSE AMOUNTS <br />RINSATE DISPOSAL SITE <br />- <br />MANIFEST # OR OTHER <br />V <br />A <br />P <br />0 <br />VAPORS PURGED &N) <br />READING AT REMOVAL <br />METHOD AMOUNT USED <br />L.E.L.: 02: <br />R <br />COMMENTS <br />C <br />O <br />TANK MATERIAL ( TE �, FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, 0!0O, HOLES) <br />T <br />PIPE MATERIAL , FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) L1�k�wti. , i mc�tC( (.��c'Z 4r-, C' v"L` `✓� <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />EXCAVATION SIZE 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 OBSERVATION SAMPLE # <br />_ <br />TRENCH DIMENSION X X YDS OF SOIL <br />LL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />___7 <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />