Laserfiche WebLink
l PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> / SITE NAME JADDRESS,51DEi-Ma;;� CITY <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT , <br /> REMOVAL ``�� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR .27�f ccs DATE �-J- 4o TANK if 39 <br /> R RINSED O(YN) METHOD RINSE AMOUNT Jr fv� <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD -) AMOUNT USED '�fSlew <br /> A <br /> P READING AT REMOVAL L.E.L. : u F 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> ° r <br /> us e NO Dh Vid-tco <br /> N TANK CONDITION (GOOD, , OOR 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 <br /> Aw <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 /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H , <br /> 2 if HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> vs <br /> LABORATORY: �N%e r SAMPLERS NAME: <br /> Ql � <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94} PROVIDE SITE MAP <br />