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it <br /> PUBLIC HEALTI ERVICES-ENVIRONMENTAL HEA "3 DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME OWNER PHONE , <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT # <br /> REMOVAL _ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE g ( TANK # 39 <br /> R RINSED E)N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE I <br /> S ! <br /> E IMANIFEST OR OTHER <br /> i <br /> V VAPORS PURGED (O�VN) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: ` <br /> 0 # <br /> C TANK MATERIAL EEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, O , HOLES) <br /> S ; <br /> T PIPE MAT <br /> ERIAL (S EEL IBERG , OTHER) # FEET <br /> PIPE CONDITION (GOOD, OOR LES <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A L+�? 6R DISC Z�IU i <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 SVW <br /> N E <br /> i <br /> G <br /> Ll I i <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> $ DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> I <br /> LABORATORY: SAMPLERS NAME: I ' <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> I <br /> EH 23--0043 (REV 2/23/94) PROVIDE SITE MAP <br />