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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE C ADDRESS /�/L) 1. <br /> WNER NAMES, J. �6`LL a OWNER PHONE # <br /> CONTRACTOR �j'S L/t� f CONT. PHONE # <br /> IRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR LG` iAll,L DATE6,15-aS TANK # 39 J <br /> R RINSED (Y .N) METHOD RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE TAnj t< A au, as ��f���o Fr i G <br /> S p <br /> E MANIFEST # /S.�( �i Q _� OR OTHER <br /> V APORS PURGED (Y N) METHOD (�,�fi lL L AMOUNT USED,-, <br /> A <br /> P FADING AT REMOVAL L.E.L. : L `` 02 : j <br /> O <br /> R OMMENTS <br /> C TANK MATERIALSTEE , FIBERGLASS, OTHER oma . <br /> A)n � . <br /> 0 <br /> N TANK CONDITION (GOOD00 , HOLES) <br /> T PIPE MATERIAL - STEEL, FIBERGLASS, OTHER) # FEET <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T ` . <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X 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: 3 �� <br /> 0 � , <br /> OTHER SAMPLE. <br /> LABORATORY: J SAMPLER NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />