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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITEN G ADDRESS 610 CITY <br /> OWNER AME OWNER PHONE # <br /> CONTRACTOR'R,.mco N CONT. PHONE # <br /> FIRE PERMIT ,# - cS7�a Fi re, rc /l e;4 S i f;e- psi e at a S TSod o Ig <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ,, S DATE 3,1 - 1 �o TANK # 39 I r 6 -'5 <br /> R RINSED (Y/N) METHOD '� rn��J RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE �' P vQ� --S &I/ J() <br /> S <br /> E JIMANIFEST # OR OTHER <br /> V VAPORS PURGED (Y N) METHOD I,r��� AMOUNT 'USED <br /> A 7.R <br /> P READING AT REMOVAL L.E.L. : �, 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STE , FIBERGLASS, OTHER) <br /> 0Hhu/e b DRi G SQ/LJ <br /> N TANK CONDITION (GOOD, 00 HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T r _ <br /> A C77 <br /> N na <br /> K # <br /> S EXCAVATION IZ X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE r` <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: <br /> LABORATORY: sfi SAMPLERS NAME:Wes-t —ENO rOW 0x,07' <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> RJ. � 753"0 ai o/d �-� <br /> �� �}-1so TANK 'f /�QcQ <br />