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PUBLIC HFALTH SERVICES -ENVIRONMENTAL - ?EALTH DIVISION <br /> SITE NAME " p"-Ip <br /> l I t R- ADDRESS6� � �; <br /> 1 7 T/l! CITY �R/7C <br /> OWNER NAME .$c,� , yLx, OWNER PRONE # 75 ,�k a <br /> CONTRACTOR (�°y� E�z1z „1 CONT . , PHONE , <br /> FIRE PERMIT' Ail L of Kcf T /U1CJS �ic(7ijyL(j�f - <br /> REMOVAL "Z CLOSURE IN PLACE TEMPORARY CLOSURE <br /> c� _r <br /> INSPECTOR L-0tit] �` y � DATE ) 1"� TANK 39 f <br /> fl 1 - r <br /> R RINSED /( /N ) METHOD �� Q,-, RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE r�Uv ( 'D p <br /> S <br /> E MANIFEST # OR OTHER <br /> PV VAPORS PURGED ( Y/N) METHOD �� CCS AMOUNT USED <br /> P READING AT REMOVAL E . L . r �aG2a 02 : <br /> O <br /> A --�- <br /> R COMMENTS / ) T Tp (,U <br /> C TANK MATERIAL TEEL; FIBERGLASS , OTHER) <br /> 0 <br /> N TANK CONDITION '(�OID), POOR , HOLES ) <br /> S 11 <br /> T PIPE MATERIAL ( STEEL , FIBERGLASS , OTHER ) # FEET <br /> PIPE CONDITION ( GOOD , POOR , HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE ,# <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M_ DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> PP I All) <br /> L I <br /> I Pv� i )� <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G . W . : _ FT . SAMPLING METHOD F 0 kIu S f <br /> H <br /> 2 J4 HOURS SINCE DEWATERING : <br /> 0 <br /> OTHER SAMPLE : <br /> LABORATORY : �re' to 1;70 ACL SAMPLERS NAME : <br /> CLOSIIRE IN PLACE I MIXTURE : VOLUME : <br /> EH 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />