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ci�kwTj <br /> � <br /> PUBLIC .EALTH SERVICES -ENVTRONMEN _ HEALTH DIVISION <br /> N <br /> SITE N I`ri Stcr Ho cs ADDRESS X325 CITY <br /> OWNER NAME ( OWNER PHONE <br /> CONTRACTOR hou� � C) , CONT . PHONE € <br /> FIRE PERMIT <br /> REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ,/pSh okcL DATE � ( Z /Q TANK 39 jays OZ <br /> R RINSEDY�N ) METHOD RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE f\IOv- Cai <br /> S <br /> E MANIFEST r OR OTHER <br /> V VAPORS PURGED (tN) METHOD _ ICS AMOUNT USED <br /> A <br /> P READING AT REMOVAL L . E . L . : 02 : 0 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STE FIBERGLASS , OTHER ) <br /> O <br /> N TANK CONDITION ( GOOD , HOLES ) I 'l <br /> S <br /> T PIPE MATERIAL qiiiiFIBERGLASS , OTHER ) FEET <br /> PIPE CONDITION ( GOOD POO , HOLES ) CC�^ ( LS.Id✓� <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE s <br /> T I n 5oi 1 Q�lcx T - Z <br /> A I <br /> N �caen � k <br /> x <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 /> Ll <br /> TRENCH D =SION X X YDS OF SOIL <br /> DEPTH TO G . W . : FT . SAMPLING METHOD <br /> H <br /> 2 s HOURS SINCE DEWATERING : <br /> 0 <br /> OTHER SAMPLE : <br /> Li I -E <br /> LABORATORY : SAMPLERS NAME : <br /> CLOSURE IN PLACE I MIXTURE : VOLUME : <br /> EH 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />