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0 <br />5� <br />AA <br />PUBLIC HEA�,l'H SERVICES -ENVIRONMENTAL hmALTH DIVISION <br />SITE NAMES <br />ADDRESS l g� <br />CITY <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTOR j,lvtp <br />CONT. PHONE # <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTORCi,51(Gkc_ DATE (Z/�Z3/C� TANK # 39 f CUP O (n <br />R RINSED ((�JN) METHOD Q RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />� z d � p-L�oc- <br />S <br />E JIMANIFEST <br /># <br />OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED ((To,) <br />READING AT REMOVAL <br />COMMENTS <br />METHOD Vii` � � AMOUNT USED <br />L.E.L.: 02: <br />C <br />TANK MATERIAL STEELFIBERGLASS, <br />OTHER) <br />` <br />0 <br />N <br />TANK CONDITION (GOOD,POO <br />, HOLES) <br />! �`�`US101 �--' c�J�sl� <br />S <br />T <br />PIPE MATERIAL (STEEL, <br />FIBERGLASS, OTHER)T# <br />FEET <br />PIPE CONDITION ( GOOD, <br />POOR, HOLES) <br />� V <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />,� 4 /S e <br />"' <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 />_ <br />TRENCH DIMENSION <br />X X <br />YDS OF SOIL <br />LIJOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.: (Z�C_)`t- FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />