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PUBLIC HATH SERVICES-ENVIRONMENTAL _A.LTH DIVISION <br /> SITE NAME i1'r ADDRESS gzvo . n)w y �� CITY <br /> OWNER NAME G�/�Tra OWNER PHONE E <br /> CONTRACTOR �r CONT. PHONE <br /> FIRE PERMIT <br /> S"S Ga_ <br /> REMOVAL—>'oCLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �v�r DATE ,f28;A;'t( TANK 39 /bl7 <br /> R RINSED a7�1) ME'S`HOD�,�r/ r RINSE AMOUNT- Off(,,, <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED <rY>/N) J METHOD Y r G� AMOUNT USED 7�d <br /> A <br /> P READING AT REMOVAL L.E.L. �a 02: � <br /> O <br /> R COMMENTS <br /> C TAPIR MATE—RTAI, (Sl FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, C7 . HOLES) <br /> S <br /> T PIPE MATER.IAIL FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, OOR, HOLES) <br /> DEPTH SOIL TYPEOBSERVATION SAMPLE <br /> T <br /> A <br /> N 5'' (9;E5`7 Gov �a►2 T k-2-w I <br /> t ! ! I <br /> S EXCAVATION SIZE -- X -'Srr` X 'V4-r YDS OF SOIL ren <br /> A <br /> M DEPTH SOIL TYPE (OBSERVATION SAMPLE <br /> p p I <br /> L I <br /> I P <br /> N E I <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: G---p/%l4r..F'Tro't`L- <br /> SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME:. <br /> f <br /> aq 23--0043 (REV 2/23/94)' PROVIDE SITE MAP <br />