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\' <br />SITE NAME <br />ADDRESS L) `L) <br />CITY3toC-1< <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTOR <br />CONT. PHONE # e't-ccs, <br />FIRE PERMIT # G% <br />A <br />REMOVALX CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR Ly <br />DATE TANK # 39 <br />R <br />I <br />RINSED Y/ ) <br />METHOD c _ <br />RINSE AMOUNT <br />N <br />RINSATE DISPOSAL SITE <br />Lam, v1 \j 1 <br />E <br />JIMANIFEST # C® OR OTHER <br />V <br />A <br />P <br />O <br />R <br />VAPORS PURGED Y ) <br />READING AT REMOVAL <br />COMMENTS <br />METHOD �� GCS AMOUNT USED o t <br />L.E.L.: 02: <br />C <br />0 <br />TANK MATERIAL (STEEL, <br />FIBERGLASS, OTHER) L <br />N <br />S <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />POOv^ gPd <br />T <br />PIPE MATERIAL (STEEL, <br />FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />A <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />t <br />L <br />EXCAVATION SIZE <br />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 />E <br />Ll <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />TRENCH DIMENSION <br />-- <br />X X YDS OF SOIL <br />I I <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />m <br />