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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> h - <br /> SITENAME ADDRESS W CITY� - <br /> OWNER NAME OWNER PHONE ,# <br /> CONTRACTOR r CONT. PHONE <br /> FIRE P T <br /> REMOVAL �r CLOSURE TN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK39 <br /> R RINSED ( ) METHOD =RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OAR <br /> V VAPORS PURGED (Y/ } METHOD AMOUNT USED 2-CF� <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : 3 <br /> O <br /> R COMMENTS <br /> C TANK MATERI STEg , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, OOR <br /> S ) HOLES) <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) , FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T DEPTH SOIL TYPE OBSERVATION SAMPLE 0 <br /> A -b' / <br /> N <br /> K <br /> S EXCAVATION SIZEI li 4j_SX 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 /> DEPTH TO G_W. : FT. SAMPLING METHOD <br /> H <br /> 2 ,# HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME- <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> 4 <br /> - 1 <br />