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3ca"o� LAO <br /> PUBLIC--" FAITH SER7 CES- _ON=-- , HEALTH DIVISIO <br /> SITE NAME Stu,r ADDRESS l A( f40(6o I <br /> CITY Ira <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR ��,-per o'.l CONT. PHO <br /> FIRE PERMIT <br /> REMOVAL N/,'- CLOSURE IY PLACE TCRARY CLOSURE <br /> INSPECTOR �jC,sh rp�G0. DATE (o c� TANK .4 39 <br /> R RINSED M=OD RINSE AMOUNT <br /> Z <br /> N RINSATE DISPOSAL SITE Nam <br /> S <br /> E MANIFEST OR OTHM <br /> V VAPORS PURGED <?JN) METHOD �, J�� AMOUNT USED d <br /> A <br /> P READING AT RMOVAL � L.E.L. : Q 7 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL TE FIBERGLASS, OTHER) <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> tqc) <br /> S <br /> T PIPE Nr-ATERTAL FIBERGLASS, OTHER) FEZT <br /> PIPE CONDITION (GOOD, �, HOLES) . <br /> DEPTH ISOIL TYPE JOBSr^RVATION SAMPLE <br /> I T F <br /> N <br /> K I ! <br /> S EXCAVATION SIZE X x YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSM=109 SAMPLE r <br /> P P <br /> L I f <br /> I P f <br /> N E <br /> G <br /> TRENCH DIlNSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT_ SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOL"u'ME: <br /> ER 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />