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PUBLIC HEALTH SERVICES ! ENVIRONMENTAL H7-A.LTH DIVISION <br /> SITE NAME ]r .nr�,.. ADDRESS a }G" i ' �. CITY <br />� <br /> OWNER PHONE OWNER NAME��� f1ll' ,U�"---- <br /> I <br /> CON'T'RACTOR CONT. .PHONE `- <br /> FIRE PERMIT <br /> REMOVAL /_ CLOSURE IN PLACE " TEMPORARY CLOSURE <br /> INSPECTOR DATE.I. Gy TANK 0 39 <br /> E R RINSED (Y METHOD METHOD RINSE AMOUNT <br /> x <br /> N RINSATE- DISPOSAL SITE <br /> S tic{•��. � -rl�- <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED &/N) JMETHOD.. L1AMOIINT USED <br /> A <br /> PREADING AT REMOVAL L.E.L ;; 02: <br /> o L. <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL,�FIBER � , OTHER) <br /> 0 -- <br /> N TANK CONDITION Q(G O POOR, .HOLES) <br /> S = <br /> T PIPE MATERIAL flBERGLA OTHER) ,# FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH I SOIL TYPE OBSERVATION SAMPLE <br /> T .. <br /> A r - L <br /> S EXCAVATION SIZE X �f X YDS OF SOIL ''�� � y `J`� "`f <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE P <br /> N E <br /> G <br /> TRENCH DIl=SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> iL—L] LABORATORY: ! ` // SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />