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SITE NAMEADDRESS <br />[CITY 5., 1 <br />3 3oz- ('2 -o&i: <br />OWNER NAME <br />G` C <br />OWNER PHONE <br />CONTRACTOR cif <br />CONT. PHONE` <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE TANK 1 39 <br />R <br />RINSED { ) METHOD <br />r`, RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE -- <br />S <br />E <br />1MANIFEST # <br />OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED ) <br />READING AT REMOVAL <br />COMMENTS <br />TANK MATERIAL rSTEEL, <br />METHOD e ,Ce- AMOUNT USED <br />L.E.L.:�1la 02: <br />FIBERGLASS, OTHER) <br />G <br />C <br />0 <br />N <br />TANK CONDITIONGOOD <br />POOR, HOLES) <br />c� <br />S <br />T <br />PIPE MATERIAL STEEL <br />FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE` <br />cen <br />n <br />GCr' � 7S:C— alS <br />9 me <br />EXCAVATION SIZE <br />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 />E <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />TRENCH DIMENSION <br />X X YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: 0<1®J(\ R( / SAMPLERS NAME: �� S; t <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />