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PUBLIC Ht)e!i'H SERVICES-ENVIRONMENTAL NeALTH DIVISION <br /> SITE NAME ADDRESS CITY , <br /> rr <br /> OWNER NAME TOWNER PHONE -0 <br /> CONTRACTOR CONT. PHONE 0 <br /> FIRE PERMIT , <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ,�'� �� DATE t4 JZj TANK 0 39I _ <br /> R RINSED Y ) METHODWW RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST 0 OR OTHER <br /> V VAPORS PURGED ON) METHOD AMOUNT USED s� <br /> A <br /> P READING AT REMOVAL L.E.L. : �j 02 : <br /> O <br /> R COMMENTS JOE�C�- lJck avo ,lolal� <br /> C TANK MATERIAL TE , FIBERGLASS, OTHER <br /> O <br /> N TANK CONDITION (GOOD, OOR HOLES) <br /> S <br /> T PIPE MATERIAL T , FIBERGLASS, OTHER) 170 FEET <br /> PIPE CONDITION (GOOD, OR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> T <br /> Su No <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL �d R <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPL , <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 0 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 />