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PUBLIC HEALTF-SERVICES-ENVIRONMENTAL HEPNTH DIVISION f <br /> SITE NAME 4f&-) ADDRESS 4t5 P#aRc_ CITY 5� <br /> OWNER NAMEAfma �J7 w- OWNER PHONE , _ zo-�.. <br /> CONTRACTOR 60uc' CONT. PHONE ,# ­5�M��Up)ft <br /> FIRE PERMIT ` 94 1 <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE4- S 44- TANK # 39 <br /> R RINSED ON) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ON) METHOD ��� �� AMOUNT USED�,�-� S <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : 3�� <br /> L0 I_ <br /> RJ COMMENTS <br /> C TANK MATERIAL EEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, R, HOLES) <br /> S <br /> PIPE MATERIAL TEE FIBERGLASS, OTHER) ,# :FEET <br /> PIPE CONDITION (GOOD, <br /> n__ <br /> , 6ixjgES 12 <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T ( L Lftq '?-LI&Ver 6bM- NO S # <br /> AL3 GOtk'T- l <br /> N GoaA t.ay 4 <br /> K <br /> l -r <br /> S EXCAVATION SIZE 4L X X YDS OF SOIL - <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P13 6f� SLm <br /> I I S P f� <br /> I P Ar <br /> N E <br /> G <br /> TRENCH DIMENSION 3 X 3 X Z4 X 3 JYDS OF SOIL <br /> DEPTH TO G.W. : FT. q.3 SAMPLING METHOD <br /> H <br /> 2 ,# HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE FMIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP ' <br /> i <br />