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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS CITY <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTOR <br />CONT. PHONE <br />&a\) trove mtnfa Sevvcu, <br />FIRE PERMIT <br />Ad 00 <br />REMOVALn / CLOSURE IN PLACE TEMPORARY CLOSURE <br />A <br />INSPECTOR <br />DATE Jr TANK 0 39 J_El <br />R <br />N <br />S <br />E <br />RINSED (1/1,T) RINSE AMOUNTI ry <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED <br />READING AT REMOVAL <br />COMMENTS <br />METHOD AMOUNT <br />L.E.L.: 02: <br />C <br />0 <br />TANK MATERIAL (STEEL, <br />FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />I ? r <br />PIPE MATERIAL (STEEL, <br />FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />A <br />T <br />A46 <br />N <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />11. <br />"'I blL <br />-141, <br />-/A im <br />woo <br />f-ul tI/vr v LkLe. <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 />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />TRENCH DIMENSION <br />X X YDS OF SOIL <br />LIJOTHER <br />2 <br />0 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />[-CLOSURE IN PLACE MIXTURE: T VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />