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PUBLIC Fn.mr,TH SERVICES-ENVIRONMENTAL aEALTH DIVISION <br /> SITE NAMECV�l '6 ' ADDRESS /Z/U CITY S M <br /> • OWNER NAME OWNER PHONE RO _ S�3 -3 <br /> CONTRACTOR4/11 ,���� j CONT. PHONE W6-3 7z- <br /> FIRE PERMIT � 6-a <br /> REMOVAI,�Z'-"' CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR � DATE 6-//-y-6 TANK 0 39 1 ZS <br /> R RINSED /N) METHOD �'{- er P-1-NSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E 11 MANIFEST � Gj ,� 3S` OR OTHER <br /> V VAPORS PURGED 6/N) IM=00 TV-- AMOUNT USED 3 Uo <br /> A <br /> P REDING AT REMOVAL L_E-L_ : 02 : z— 7- <br /> 0 <br /> R j COMMENTS Trcr— 4- C7$, <br /> C TANK MATERIAL TE , FIBERGLASS, O'I*:iER) <br /> O <br /> N TANK CONDITION (GOOD OO , HOLES) uler.� <br /> • S <br /> T PIPE MATERIA,L (STEEL, FIBERGLASS , 0THE.4) ira FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) (reti.,,y�c� <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T <br /> A S- I <br /> N I aI r- <br /> K � <br /> S EXCAVATION SIZE X .3 y XI� ' YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P I I I <br /> L I <br /> I P <br /> T- <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 1:101URS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE.: <br /> • LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />