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i <br /> PUBLIC HEALTH SERVICES — ENVIRONMENTAL HhALTH DIVISION <br /> SITE NAME F.661vrf �i2 rADIDRESS /7l 15 <br /> -�` ��(J CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOI„ij�,O �J1 Jam. ,4 20 CONT . PHONE # <br /> FIRE PERMIT # i xi/3 G y �< < Oi K %✓irk /4� ywov 2� <br /> v <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR -2 fi � — i � DATE 7-� J , 55 TANK # 39 L� <br /> R NSEDY N METHOD � ? n RINSE UNT <br /> I pp,� <br /> N RINSATE DISPOSAL SITEN� U ( JJ r/L 64 Po <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED Y N) TROD l�i�, �� AMOUNT USED <br /> A -7 <br /> P READING AT REMOVAL L . E . L . : 02 : ` / <br /> O <br /> R COMMENTS <br /> C TANK MATERIALTEEL FIBERGLASS , OTHER ) <br /> O <br /> N TANK CONDITION ( GOOD , POOR , HOLES ) <br /> S <br /> T PIPE MATERIAL ( STEEL , FIBERGLASS , OTHER ) # FEET <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A 7 , L71 Sam / <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 <br /> I P <br /> N E <br /> G <br /> Ll <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 : <br /> LABORATORY : 1 wa r ` /n a &c SAMPLERS NAME : <br /> CLOSURE IN PLACE MIXTURE : VOLUME : <br /> EH 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />