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Sao c�� Ui(gT <br /> PUBLIC ' EALTH SERVICES-ENVIRONMEN_ HEALTH DIVISION <br /> SITE NAME 1r �{ tzu ADDRESS13� A( Cr rr0.( 40 ( (0 CITY <br /> OWNER NAME ( OWNER PHONE <br /> CONTRACTOR �c, �� G � � ( CONT . PHONE <br /> FIRE PERMIT i <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �1/os 1 ( oko4 DATE 6 2 4�4 TANK 39 <br /> R RINSED (2N ) METHOD RINSE AMCU2T <br /> I <br /> N RINSATE DISPOSAL SITE O P (2O( <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED &JN ) METHOD i' � ., AMOUNT USED of <br /> A <br /> P READING AT REMOVAL I L . E . L . : Q 02 : Q <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL ((E4 , FIBERGLASS , OTHER ) <br /> 0 <br /> N TANK CONDITION ( GOOD , POO , HOLES ) (�� ( <br /> S <br /> T PIPE MATERIAL EEL FIBERGLASS , OTHER ) FEET <br /> PIPE CONDITION ( GOOD , , HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE r <br /> T IAL 1 \d I rc m o <br /> `i <br /> A I lti lo � I <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 1 <br /> T 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 J4 HOURS SINCE DEWATERING : <br /> 0 <br /> OTHER SAMPLE : <br /> LABORATORY : SAMPLERS NAME : <br /> CLOSURE IN PLACE I MIXTURE : VOLUME : <br /> W3 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />