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PUBLIC HEA}: i SZRVTCES-ENVIRONMENTAL Hl" STH DIVISION <br /> C` F <br /> iADESSSITE NAME c?�v� CITYDOLLc n ' <br /> OWNER NAME OWNER PHONE J4 <br /> CONTRACTOR 4 ( �CONT. PHONE <br /> FIRE PERMITI <br /> r <br /> REMOVAL CLOSURE --- i PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 0 39 <br /> R RINSED Y ) "SHOD fr+ 1 ` Q, RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SIT;: <br /> S Ir <br /> E MANIFESTOR OTHgtP <br /> V VAPORS PURGED Y N) I METHOD AMOUNT i USED Q <br /> A <br /> P READING AT REMOVAL L.E.L. 02: <br /> O <br /> R COMMENTS ` <br /> C TANK MATERIAL SST FIBERGLASS, OTHER) <br /> N TANK CONDITION (GOOD, POOR,(E S) <br /> S <br /> T t�ey) <br /> PIPEi?AT=TLL � FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POO HOLES) <br /> DEPTH TY-7-7 SAMPLE ,2` <br /> T €. <br /> am <br /> IG <br /> N E Lia <br /> K ' o Trf <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A �F�: <br /> M DEPTH SOIL TYPE OBSERVATION FSAPLE <br /> P P <br /> L I <br /> I P jl <br /> N <br /> G <br /> TRENCH onmgsICH X X YDS OF SAIL <br /> DEPTH TO G.W. : FT_ SAMPLING METHOD <br /> A <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 k. <br /> OTHER AMPLE: <br /> LABORATORY: Gao SAMPLERS NAME:. <br /> CLOSURE IN PLACE TEXTURE: VOLUME: k� <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />