Laserfiche WebLink
PUBLIC HEAL SERVICES-ENVIRONMENTAL HF TH DIVISION <br /> 2;� � 7jiKD <br /> SITE NAME ADDRESS al OQ�S4�r CITY <br /> OWNER N S OWNER PHONE <br /> CONTRACTOR O 1Q pkA CONT`• PHONE <br /> FIRE PERMIT ! <br /> REMOVAL V CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INS"RINSED <br /> DATE G>'2U�� TANK 39 D <br /> RN) METHOD �Y RINSE AMOUNT '� 6 <br /> I � <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST 2 OR OTHER <br /> V VAPORS PURGED ) METHOD AMOUNT USED <br /> A r <br /> P READING AT REMOVAL L.E.L. : 02: N1� <br /> 0 4y� <br /> R COMMENTS 11) <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) 5 DD <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) C '�ojZrs►. <br /> S Z / <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) rFEET <br /> PIPE CONDITION ((GO?P, POOR, HOLES) W� <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A LAD p <br /> N <br /> K <br /> S EXCAVATION SIZE �, X -CL X YDS OF SOIL <br /> ASAMPLE ,i` <br /> M DEPTH SOIL TYPE OBSERVATION <br /> P P <br /> L I 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 1 HOURS SINCE DEWATERING:F <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: G��c--.IA <br /> SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />