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PUBLIC HE,—l'H SERVICES—ENVIRONMENTAL t__ALTH DIVISION <br />SITE NAME <br />ADDRESS I� � _� <br />CITY <br />OWNER NAME ���,� <br />OWNER PHONE # <br />CONTRACTOR �����, S <br />CONT. PHONE # <br />FIRE PERMIT # / � —.:5 / C/ <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK # 39 <br />R RINSED (Y/N) METHOD RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE -� <br />cto �- <br />S <br />E <br />V <br />MANIFEST # OR OTHER <br />VAPORS PURGED (Y/N) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />_ <br />02: Z4 <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIALE FIBERGLASS, OTHER) <br />N <br />TANK CONDITION (GOOD,( 00 ,- HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES),y <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 />C�lv�.iv`n ci <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />H <br />2 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER 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 />