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PUBLIC HFA 2H SERVICES-ENVIRONMENTAL t H-.*LTH DIVISION <br /> SITE NAME/4-} }���-Q'iY1 ADDRESS�76 1 s , !� CITY <br /> O NAME S !OWNER PHONE <br /> CONTRALTOI I CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 4t I +-t o- Br ( DATE TANK # 39 ] 7 J <br /> R RINSEDYDN) METHOD-t:�:L, RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ON) METHOD 4,�� � �y AMOUNT USED <br /> AIt-7 <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) -4 FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE JOBSERVATION ( SAMPLE # <br /> T <br /> A <br /> N I Scw I Nn I-rK7 LJ <br /> � I � <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ` SOIL TYPE OBSERVATION SAMPLE � <br /> P P ( I <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DI` ENSION X X YDS OF SOIL <br /> DEPTH TO G.W. FT. SAMPLING METHOD <br /> x <br /> 2 J4 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: 7 <br /> SAMPLERS NAME: 14 e <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> Ex 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />