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PUBLIC MWTH SERVICES-ENVIROMMiTAL OLTH DIVISION <br />SITE NAMEADDRESS (CITY <br />OWNER NAME ! OWNER PHONE <br />CONTRACTOR `CONT. PHONE # <br />FIRE PERMIT # I <br />REMOVAL CLOSURE l' PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK if 39 <br />R RINSED (Y/ -,q) I =00 R�-'YSE AMOUNT <br />I .. <br />N RINSATE DISPOSAL SITE <br />S <br />E MANIFEST # OR OTHER <br />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 i r TYPE JOBSZRVATION S <br />all <br />C� <br />TAl\T.K 'MATERIAL <br />(M=-, <br />FIBERGLASS, OTHER.) <br />0 <br />N <br />TANK CONDITION <br />(GOOD, <br />POOR, HOLES) <br />S <br />T <br />PIPE MATEIRIAL <br />( STEEL, <br />F BERGLASS , 02�) <br />'PIPE CONDITION <br />(GOOD, <br />POOR, HOLES) <br />DEPTH ISOIL TSE <br />I OBSERVATION <br />A <br />I <br />I <br />N <br />I <br />I J <br />I <br />A <br />M <br />P P <br />L I <br />I P <br />N E <br />G <br /># FEET <br />rm�40-- <br />EXCAVATION SIZE x x <br />YDSOF i <br />DEPTH i r TYPE JOBSZRVATION S <br />all <br />II ~T�..�YCH DIMENSION X <br />DEPT`H TO G.W. FT. <br />H <br />2 # HOURS SINCE DEWATv=TG: <br />0 <br />OTQ". M SAMPLE: <br />LABORATORY: <br />CLOSURE LV PLACEXTt3RE: <br />., 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />