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PUBLIC HEAr-TH SERVICES-ENVIRONMENTAL F"ALTH DIVISION , <br /> SITE NAME ADDRESS _ CITYS <br /> OWNER NAME (OWNER PHONE <br /> CONTRACTORCONT. PHONE , <br /> FIRE PERMIT ` <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK ,# 39 <br /> R RINSED ( N METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST P OR OTHER <br /> V VAPORS PURGED C(qN) I METHOD AMOUNT USED U L <br /> A <br /> P READING AT REMOVAL L.E.L. : 1 02 : s <br /> O 1 <br /> R CODO=S <br /> C TANK MATERI STE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR) HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) , FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE _4Zf X 2�6 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- --TSAMPLING METHOD <br /> r02 <br /> HOURS SINCE DEWATERING: <br /> F <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 /> 0'7� � <br />