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PUBLIC HEALTF; ERVICES-ENVIRONMEN'T`AL HEAD DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME OWNER PHONE if <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR k)C� DATEQgjq4 TANK 39 <br /> R RINSED N} METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST , OR OTHER <br /> IpVAPORS PURGED N) METHOD AMOUNT USED <br /> READING AT REMOVAL L.E.L. : 02: 4 A T <br /> COMMENTS'rft V <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD,TW,, HOLES) <br /> S <br /> T PIPE MATERIAL STE IBERGLASS OTHER) FEET ID5L <br /> PIPE CONDITION (GOOD, OR OLES <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE 3f <br /> T Ctn- <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X 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: 7 <br /> VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />