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PUBLIC &TH SERV ICES-ENV=RONMENT EALTH DIVISION <br /> SITE NAi`�� '6 I JADDRESS Z/U C=TY <br /> OWNER NAML U/9'Z,r , ', OWNER PHONE r 7. _7q_ <br /> CONTRACTOR CONT. PHONE A <br /> /�al�� -�n� <br /> FIRE P ERM2T _ 1 <br /> i <br /> RIl�IOVAL_� CLOSURE IN PLAC r TEMPORARY CLOSL-RE <br /> INSPECTOR , �( �� DATE' �_//-f-6 TANK 39 <br /> R RINSED ®/N) I=OD RI=SE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFESTOR OTHER <br /> V VAPORS PURGED (DN) �METHOD TLI-1- AMOUNT US= 360 /IJj <br /> A <br /> P READING AT R—%'T C VAL D.E.L. : 02 : <---9 <br /> 0 <br /> R CObulENTS � <br /> C TAYK v-AT=.—r:LL STz' , =r E.4GT-ASS, OTHER)0 E <br /> N TANK CONDITION (GOOD, _COR 30LES) <br /> S O <br /> • I T PIKE MATE—IL (STEM, =ERGLASS, OT=) <br /> I <br /> PIPE CONDITION (GOOD, POOR, EOL.ES) *11► YW <br /> T <br /> DEPTH f SOIL TYP-w I OBSERV.ITION � SAmK?Lz � <br /> -1 - <br /> R I I 1 ! ! <br /> ! I <br /> S EXCAV2�TION SIZE X L� X vDS OF SOIL <br /> A <br /> u DEPTH SOIL TYPE OBSMEZVATION S.A-m-PL" r <br /> P P ! ! ! I <br /> L I { I ! <br /> N E ! ! <br /> G <br /> t <br /> TR-TCH DI2fENSION X X YDS OF So--,L <br /> DEPTH TO G_W. : FT. lSAMPLING im-=OD <br /> I H i <br /> 2 r-z HOURS SINCS DEWAT-7=21G: <br /> 0 <br /> OT3�'-4 SAMPLE.: � <br /> iI LABORATORY: � . SAIA-mLx-MS RAML IZ: <br /> CLOSURE IN PlACE � .ARE: l 70LUM2 <br /> Ell 23-0043 (,R_cV 2/23/94) PROVIDE SITE MSP <br />