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�� ePUBLIC .EALTH SERVICES— ONMEN_ -" HEALTH DIVISION <br /> SITE NAME - rt Sent A4owic.S ADDRESS 25' N, co,rca Houow CI'T"r T�rGtC <br /> OWNER NAME TOWNER PHO TE i <br /> CONTRACTOR �a 0% CONT. PHONE ��Lq� �� _ l•�� <br /> FIRE PERMIT 20 <br /> REMOVAL X CLOSURE nT PLACE TZ14PORARY CLOSURE <br /> INSPECTOR YOS h c5 ka. DATE (o /Q TANK P 39 <br /> R RINSED KfN) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE 6,, cd <br /> S <br /> E JIMANIYEST OR OTHER <br /> V VAPORS PURGED] (:bN) METHOD . AMOUNT USED p�- r <br /> A --�: <br /> P READING AT REMOVAL L.E.L. : E02: 0 <br /> 0 <br /> R COMSm TS <br /> C TANK MAT.r�'RI.AL STE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 4!n, HO ) �l__ t <br /> S `�C� <br /> T PIPE I T—ti'RT_AL (Z� FMERGLAS , OTHER) FEET <br /> PIPE CONDITION (GOOD POO , D30 S) <br /> ^�, ros tam <br /> DEPTH I SOIL TYPE OBSERVAT ON SAMPLE <br /> x A I u-,6 I toy l - Z <br /> N ! I I <br /> S 14-caczm t� - 1 <br /> I <br /> S EXCAVATION SIZE, X x YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE ` <br /> P P <br /> L I I <br /> I P I <br /> EFTRENC: DI=SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> I H <br /> 2 24 HOURS SINCE DEWATER=NG: <br /> LL4 <br /> 'i : - . <br /> OTHER SAMPLE <br /> LABORATORY: I SAMPLERS NAME: <br /> 1==QSUR-w IN PLACE I MIXTURE: VOLUME: <br /> rtl 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />