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PUBLIC HW04H SERVICES-ENVIRONMENTAL HfVISLTH DIVISION <br /> SITE NAME nIOVe. C,0 ADDRESS <br /> I )vAA;4J <br /> Y <br /> OWNER ti OWNER PHONE a4 <br /> ell <br /> CONTRACTOR - teCONT. PHONE <br /> ` - <br /> I <br />` FIRE PERMIT <br /> o i <br /> REMOVAL_ CLOSURE n-f PLACE TEMPORARY CLOSURE <br /> INSPECTOR .0 j �, DATE //- TANK P 39 <br /> R RINSED Y ) y SHOD /`-IL Q� RINSE AMOUNT <br /> I /J a0 <br /> N RINSATE DISPOSAL SITZ" <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ,'(Y <br /> A � U N) ,METHOD �G j AMOUNT USED ��G [s <br /> P READING AT REMOVAL N L.E.L. : � 02 : <br /> + O <br /> R COMMENTS <br /> C TANK MATERIALSTEEL„FIBERGLASS, OTHER) <br /> 0 i <br /> N TANK CONDITION (GOOD, POOR <br /> S EL::E <br /> S} a' ' - <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T ) <br /> A ^ I ° n�/ .L r err •. �i f1/Y/ti <br /> N <br /> K Ag <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE 0 <br /> P P <br /> L I <br /> I P <br /> N E I I <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 r# HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/940 PROVIDE SITE MAP <br />