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1, PUBLIC HF ' TH SERVICES -ENVIRONMENTAL ALTH DIVISION <br /> SITE NAMEADDRESS ' CITY <br /> �G �! CITY n <br /> ) S / n 7- Ai <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR &(f 6,q-te i CONT . , HQNF # <br /> FIRE PERMIT i4 GK 'oj Ta n1 �Soz. � <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR o , we //fk , kz K� 1JL DATE - J -S ANK # 39 Q j <br /> R RINSED &N ) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE /_ ro jPe , (� <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED . ( Y.yN ) METHOD 1� �Lu L� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L . E . L . : � g , � 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL TEEL ; FIBERGLASS , OTHER ) <br /> 0 <br /> N TANK CONDITION " (`Oq , POOR , HOLES ) <br /> S <br /> T PIPE MATERIAL ( STEEL , FIBERGLASS , OTHER ) # FEET <br /> PIPE CONDITION ( GOOD , POOR , HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> AScy�vl L06U ,T <br /> N �s <br /> K S ' — <br /> --b � <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> mDEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> 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 . : / i FT . SAMPLING METHOD WI+rt,vv <br /> H <br /> 2 # HOURS SINCE DEWATERING : <br /> 0 <br /> OTHER SAMPLE : <br /> LABORATORY : SAMPLERS NAME : <br /> CLOSURE IN PLACE MIXTURE : VOLUME : <br /> EH 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />