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PUBLIC SERVICES-ENVIRON14ENTAL SALTH DIVISION <br />SITE NAME jfiy, YM <br />ADDRESS 3,�66 A U)t&7l-kV_f(A_ <br />CITY <br />OWNER NAMEJIZ <br />OWNER PHONE (S? 16) 3 73 - / 16F <br />CONTRACTOR W'ah'0_*'t- <br />Ai rF-A <br />CONT. PHONE <br />FIRE PERMIT 9 -7 <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />j2E 4 ra UPS <br />INSPECTOR/*r/�(DATE//-�/-?j TM4X 39 z <br />R <br />RINSED (Y/W) METHOD RINSE AMOUNT <br />N <br />RINSATE DISPOSAL SITE <br />S <br />L E <br />V <br />MANIFEST OR OTHER <br />VAPORS PURGED (Y/N) iMZ OD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL L.E.L.: <br />02: 5% <br />0 <br />R <br />COMMENT <br />C <br />TANK MAT(STEEL FIBERGLASS, OTHER) <br />(LT <br />0 <br />N <br />TANK CONDITION (GOOD, POOR, HOLES)cow�sio' <br />too <br />&L ]At <br />S <br />T <br />PIPE MATERIAL;(STEM, FIBERGLASS, OTHER) <br />FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE (OBSERVATION SAMPLE <br />6-&L 'r 37Z..Am, TF I A7 <br />Q- o' cl u vao�' - <br />1TFI _3 '5 -E -]3s I <br />EXCAVATION SIZE x X <br />YDS OF SOIL <br />A <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 />2 <br />L0.171-1 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />HOURS SINCE DEWATERING: <br />. SAMPLE: S +0 C, iel <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACEI I MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />I <br />