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j PUBLIC HEAL--- SERVICES-ENVIRONMENTAL HEALTH DIVISION- <br /> SITE NAME V� I `Jj ADDRESS CITY Q <br /> OWNER NAME/ a-1 <br /> OWNER PHONE <br /> CONTRACTOR /,� CONT. PHONE <br /> FIRE PERMIT ,# / <br /> OVAL__ Z CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �7 - DATE.6 TANK # 39 /-7 �r Z <br /> R RINSED Y,/N) METHOD 7 j !e_ RINSE AMOUNT 6 ' <br /> I <br /> N iRINSATE. DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED .&/N) METHOD 3 , Ze- AMOUNT USED/o3 <br /> A <br /> P READING AT REMOVAL L.E.L.. : All ", 02 : f <br /> O �! <br /> R COMMENTSAx IV-,-I t 17 A�/p <br /> C TANK MATERIAL ( TE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, qcoo?, HOLES) c <br /> S _ <br /> T PIPE MATERIAL TE , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, OOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION; SAMPLE # <br /> T f <br /> N <br /> K <br /> S EXCAVATION SIZE 161X / Z X 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 YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: / ,; SAMPLERS NAME: �� <br /> C-;co tt� u f t ICA J_A, <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> 'I J T <br /> EH 23--0043 (REV 2/23/94) PROVIDE SITE MAP <br />