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PUBLIC IU ,TH SERVICES-ENVIRONMENTAL ALTH DIVISION <br /> SITE NAMEA Yj4l (_ 7 ADDRESS 7 � CITY S7�,O G <br /> llNFj NAME �, S r �:ri <br /> OWNER PHONE <br /> CONTRACTO ( CONT. PHONE ` <br /> FIRE PERMIT (9vt sw <br /> REMOVAL X CLOSURE nT PLACE TEMPORARY CLOSURE <br /> INSPECTOR I �-i u- DATES-JTANK t 397 <br /> R RINSED ON) METHOD--("uRINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER ` <br /> V VAPORS PURGED @/N) METHOD ��� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> O i <br /> LR CONr1I=S <br /> C i TANK MATERIAL STE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITIONGOOD POOR, HOLES) <br /> S <br /> T PIPE MAT EEL FIBERGLASS, OTHER) .4 FEET <br /> PIPE CONDITION GCOD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T I I <br /> A I - i <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE t <br /> P P I _<u l`0->� <br /> I P 3 I i <br /> N E <br /> G <br /> TRENCH DIMENSION X X rYS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> x <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> 'F CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />