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PUBLIC HEAI 7` SERVICES-ENVIRONMENTAL HE"Y,TH DIVISION F <br /> i ! --------------------- <br /> y SITE NAME]/w�l�� l I ` ADDRESS Rod CITY <br /> OWNER NAMEOWNER PHONE <br /> CONTRACTOR J ,Coe CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL R� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR eYr DATE TANK # 39 / -7 S�'Z_ <br /> R RINSED 6Y/N} METHOD RINSE AMOUNT <br /> I c G <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E JIMANIFEST # OR OTHER <br /> V VAPORS PURGED YIN) METHOD AMOUNT USED/03% , w <br /> A <br /> P READING AT REMOVAL L.E.L. : / i, � - 02 ; °a <br /> 0 <br /> R COMMENTS jjy� 5 f`�:z- 7�J`C /r•r�u�LY, Qy'tS rc . <br /> C TANK MATERIALST L; FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 60-0 HOLES) <br /> S <br /> T PIPE MATERIAL FIBERGLASS, OTHER) # FEET +�] <br /> PIPE CONDITION (GOOD, OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A ti cJ i [ c'fTA F75?k C IC <br /> N a k- l <br /> � 1 cT _� `_ <br /> K C p ` <br /> S EXCAVATION SIZE Lj X /?,- Xf YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION: SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X �� X, J � YDS OF SOIL <br /> DEPTH TO G.W. :- FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> IJL LABORATORY: r�. SAMPLERS NAME: f�- <S <br /> u <br /> CLOSURE IN PLACE MIXTURE: . VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP . <br />