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: O AL HEALTH DIVISION <br /> SITE NAME tm/3 R ADDRECITY <br /> ss#075 C. rn� S fay L <br /> OWNE.4 NAMM (OWNER PHONE j <br /> I <br /> CO CT -StV G4.t CONT. PHONE 0 <br /> FIRE PERMIT <br /> REMOVAL__ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR f1 ? a''S DATETANK 0 39 —//, <br /> R RINSED (Y/N I METHOD RINSE AMOUNT <br /> T " <br /> N RINSATE DISPOSAL SITE 6jV dI D PUr � IW3cCRa tti,��yo <br /> S <br /> E MANIFEST T OR OTHER <br /> VVAPORS PURGED (Y N) (METHOD IAMOUNT USED s ` <br /> P READING AT REMOVAL L.E.L. : 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIALSTEEL FIBERGLASS, OTHER) ,5X e-� <br /> v <br /> N TANKCONDITION (GOOD, BOOR HOLES) p R45 - <br /> I S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS I ,r FEET' .• 1, <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH ISOIL TYPE (OBSERVATION SAMPLE <br /> A I <br /> N I <br /> K I I zt' <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE c <br /> P P O <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 s HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: 5 <br /> LABORATORY: ) I S;LPLZRS NAME: ' ' N <br /> CLOSURE IN PLACE I MIXTURE: VOLmf-E: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />