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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE N SLOG Tom' ADDRESS CITY S�o � <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORr, 5 DATE ��( -'cf& TANK if 39 <br /> R RINSED &N) METHOD ') �� RINSE AMOUNT,;ro <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E JIMANIFEST # OR OTHER <br /> V VAPORS PURGED (ON) METHOD AMOUNT USED Y6_6 2C�,_ <br /> A <br /> P READING AT REMOVAL L.E.L. : 7 02: 7 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL < TEFL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) ('(tSte b yo��/0 <br /> S <br /> t <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) , FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> K FEE <br /> I, <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 /> i <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 /> ,F_CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> I <br />