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PUBLIC HEAL 'ERVICES-ENVIRONMENTAL HEAD I DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR CONT. PHONE L��uu <br /> FIRE PERMIT # <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE "f a4' TANK ` 39 <br /> R RINSED {Y N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E IMANIFEST OR OTHER <br /> V VAPORS PURGED ('X)N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS �p �ftU Uy� Zb Rb 11C LEZ. <br /> C TANK MATERIALEEL FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, PO R HOLES) <br /> S <br /> T PIPE MATERIAL STEEL FIBERGLASS OTHER) FEET L S <br /> PIPE CONDITION (GOOD, OR, S <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T O S <br /> A <br /> N <br /> R <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P C� <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 if HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: -7 SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />