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"a PUBLIC HEALTH SERVICES—ENVIRONMENTAL HEALTH DIVISION <br /> Oft _Adl <br /> SITE NAME ADDRESS f E-. ITY 57 <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT at <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ' DATE V - ` r & TANK 39 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT $D <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED ,�5 I bS <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATER (STE , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD POOR HOLES) r' to ND o%'�/i 0-C4,4-- <br /> S OCn ey 4-` <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A a <br /> N <br /> Kd <br /> S o EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE at <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: SAMPLERS NAME: <br /> E: <br /> --F-i . <br /> 3 CLOSURE IN PLACE MIXTURE: VOLUME: <br /> 1. EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> I <br />