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PUBLIC HEA"H SERVICES-ENVIRONblENTAL HEALTH DIVISION <br /> SITE NAMEA94�5-- — ADDRESS� v /� CITY <br /> OWNER NAME � OWNER PHONE "Z j 7j 5>0 <br /> CONTRACTOR Asa CONT. PHONE �- <br /> —�s <br /> FIRE PERMIT <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR r « DATE 3 TANK 39 /9 S o <br /> R RINSED MN) T METHOD ,�E - RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE �� L <br /> S <br /> E MANIFEST , OR OTHER <br /> V VAPORS PURGED ) ; METHOD ��,��- r AMOUNT USEDd <br /> A <br /> P READING AT REMOVAL L.E.L. . 02 : <br /> P <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS THEA) <br /> O <br /> N TANK CONDITION (GOOD 0 "r7 HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T ^JP VdqetS4 Y -t,WFA 4177W <br /> N <br /> K <br /> S EXCAVATION SIZE j5-..X.-- 12 X 2 '. YDS OF SOIL r,�p <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> I <br /> DEPTH TO G.W. : FT-- SAMPLING METHOD ` <br /> H - F <br /> 2 HOURS SINCE- DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME:LL <br /> �F <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23--0043 (REV 2/23/94) PROVIDE SITE MAP <br /> I <br />