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PUBLIC H' C,TH SERVICES -ENVIRONMENTAL 'T ALTH DIVISION <br /> SITENAME J�D 0405 Tlqri <br /> n , ADDRESSl�C�JY 57 CITY <br /> %RSC <br /> OWNER NAME .,S� OWNER PHONE 54 j � � 1 7 $ 0, CjUO <br /> CONTRACTOR &(f �r4�`2 + , , CONT . PHONE <br /> FIRE PERMIT Fiip - 6A`i/ teelt::;l jt /c � <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORS t r` ISP I <br /> K DATE 'TANK 39 <br /> 7IR RINSED ( Y N ) METHOD RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ( Y N) METHOD D K G AMOUNT USED <br /> A <br /> P READING AT REMOVAL L . E . L . : 02 : <br /> 0 <br /> R COMMENTS <br /> C TAMC MATER ( STEEL , FIBERGLASS , OTHER ) <br /> 0 <br /> N TANK CONDITION ( GOOD , POOR , HOLES ) <br /> S <br /> T PIPE MATERIAL ( STEL FIBERGLASS , OTHER ) FEET <br /> PIPE CONDITION ( GOOD , POOR , HOLES ) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T <br /> A ' C act .s 0 y Ll ( - <br /> N _ _ r- <br /> K li li F <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 : <br /> 0 <br /> OTHER SAMPLE : S- 'o c t< o i e, 4P ,5 -S'' i 1 } 9' � lv 's, p <br /> 1 c/7�- AS4Z n_ - <br /> LABORATORY : T�v 1pil tvC. SAMPLERS� NAME : <br /> CLOSURE IN PLACE MIXTURE : VOLUME : <br /> EH 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />