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PUBLIC HE11W SERVICES -ENVIRONMENTAL jJkLTH DIVISION <br />SITE NAME <br />ADDRESS A-rTY <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTOR l <br />CONT. PHONE <br />FIRE PERMIT #T <br />REMOVALCLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE TANK 1 39 <br />R <br />N <br />S <br />I E <br />RINSED (Y/N) V METHOD RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />JIMANIFEST # OR OTHER <br />VAPORS PURGED (Y/N) METHODUSED <br />P�o <br />V <br />A <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: <br />— <br />T 02: <br />R 11 <br />COMMENTS <br />C <br />0 <br />TANK MATERIAL (STEEL, <br />FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />Koce -s <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 f <br />b <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 />2 <br />0 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />IF—CLOSURE IN PLACEMIXTURE: <br />I VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />