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0000:1. ■'• T r91 A 1 a' <br />r r•` <br />OWNER NAME orvv- .R PHONE i <br />(CONTRACTOR `CONT. PHONE <br />i <br />FIRE PERMIT � <br />REMOVAL CLOSURE '—r4 PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK 39 <br />R RINSED (Y/N) METHOD RINSE AMOUNT <br />N RINSATE DISPOSAL SITE' <br />S <br />E MANIFEST OR OTHER <br />j v VAPORS PURGED (Y/N) � METHOD AMOUNT USED <br />A <br />P READING AT REMOVAL L.E.L.: 02: <br />0 <br />R <br />COMMENTS <br />DEPTH SOIL TYPE I OBSERVATION rSAMPLE ; e <br />C <br />vum. K-ATEP—r T• (STEEL, <br />FIBERGLASS, OTHER) <br />0 <br />R G <br />N <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />T <br />PIPE <br />MAT�.AL (S <br />F-113ERGLA.SS , OTHER) <br />DIME CONDITION (GOOD, <br />POOR, HOLES) <br />f <br />I DEPTH ( SOIL TYPE I OBSERVATION <br />A <br />D <br />L <br />I <br />N <br />G <br />H <br />2 <br />0 <br />0 <br />E�YG1vATI0N SIZE x x <br />YDS OF SOIL <br />DEPTH SOIL TYPE I OBSERVATION rSAMPLE ; e <br />`ifi ■ � <br />i!: DIMENSION : i • • <br />`ifi ■ � <br />OTHER SAMPLE: <br />LABORATORY: <br />CLOSURE r-1 PLACE I MIXTURE: P VOLUME: <br />E: -i 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />