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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESSCITY <br />OWNER PHONE ,# <br />OWNER NAME <br />CONTRACTOR ..� -h <br />CONT. PHONE # <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR 42 LC DATE TANK # 39 <br />R <br />I <br />N <br />S <br />E <br />V <br />A <br />RINSED (5N) METHOD�9 ® RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />JIMANIFEST # OR OTHER <br />VAPORS PURGED N) METHOD r--- AMOUNT USED <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: ® <br />02: 3 <br />R <br />COMMENTS <br />C <br />0 <br />TANK MATERIAL (STEEL, FIBERGLASS, THER <br />N <br />S <br />TANK CONDITION (GOODPOOR, HOLES) <br />T <br />PIPE MATERI STEEL FIBERGLASS, OTHER) <br />lf FEET <br />PIPE CONDITION (GOOD, FO HOLES) <br />S <br />A <br />T <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE f <br />La L <br />EXCAVATION SIZER Ft X/ <br />YDS OF SOIL 40 Ls <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />r. 'l r <br />® r `` ! / <br />2*6iION <br />CH X X a YD F SOIL <br />LLOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />