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PUBLIC HEALTF ERVICES--ENVIRONMENTAL HEA�' DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR, CONT. PHONE # (alp, <br /> / <br /> u <br /> FIRE PERMIT , <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE �8 TANK # 39 Z�(p EXO <br /> R RINSED N) 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 <br /> A <br /> P READING AT REMOVAL L.E.L. : 0 02: <br /> O <br /> R COMMENTS T �Jo <br /> C TANK MATERIAL E FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, O , HOLES) <br /> S - <br /> T PIPE MATERIAL EEL, ERGLA , OTHER) <br /> PIPE CONDITION (GOOD, QOR, LES <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <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 ,Arp <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 /> L--IJOTHER SAMPLE: <br /> FLABORATORY: SAMPLERS NAME: <br /> ECLos= IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />