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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS <br />TY <br />OWNER NAME <br />OWNER PHONE if <br />CONTRACTOR `6 cA__A <br />Frv\f wywA - S- v- i co 7S <br />ICONT. PHONE <br />FIRE PERMIT f q6 -P5 <br />I Al 00 U-4-1 <br />REMOVALCLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR' DATE TANK if 3 9 <br />R <br />RINSED <br />METHODR <br />V- I rv�s Et_� <br />7 t <br />��.AMO <br />N <br />S <br />RINSATE DISPOSAL SITE <br />1 E <br />JIMANIFEST OR OTHER <br />V <br />A <br />P <br />0 <br />1 R <br />VAPORS PURGED (Y/N) METHOD r -y C. C AMOUNT USED <br />I <br />READING AT REMOVAL L.E.L.: F 02: <br />11COMMENTS A7 -c -1c Act� <br />C <br />0 <br />TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, POOR, HOLES) <br />V, vvc� <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD., POOR, HOLES) <br />S <br />A <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />400 Lv V tvLx---71 LX <br />Fav ITZ) <br />EXCAVATION SIZE x X <br />YDS OF SOIL <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />TRENCH DIMENSION X X YDS OF SOIL <br />LLOTHER <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: SAMPLERS NAME: <br />,F CLOSURE IN PLACE <br />MIXTURE: _T VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />