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PUBLIC HE&TH SERVICES-ENVIRONMENTALOALTH DIVISION <br />SITE NAME,� <br />ADDRESS X36 IJ4107 CITY GprDZ <br />OWNER NAME ® <br />IOWNER PHONE <br />CONTRACTOR �� Gv,JS vc�. 1 <br />CONT. PHONE 24 <br />FIRE PERMIT <br />�Z. <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR ��,�f� DATE c1//'0,,45 TANK # 39 f f 3Gi�� <br />R <br />RINSED } METHOD CAf RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE /�®tiilG <br />S <br />E <br />MANIFEST .4 OR OTHER <br />V <br />VAPORS PURGED ) METHOD 19dAG� AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: Q <br />02: <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIALEL, FIBERGLASS, OTMIM) <br />0 <br />N <br />TANK CONDITION (GOOD OOR HOLES) <br />S <br />I <br />T <br />PIPE ER-T—AL TEFL FIBERGLASS, OTHER) FEET <br />PIPE CONDITION (GOO POOR, OLES) <br />DEPTH SOIL TYPE JOBSERVATION I SAMPLE <br />T <br />I <br />A <br />I <br />! <br />N <br />I <br />I <br />K <br />( <br />� <br />S <br />EXCAVATION SIZE 'X-SiffYL X <br />YDS OF SOIL - <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />P <br />P <br />L <br />I <br />I <br />P <br />I <br />N <br />E <br />I <br />I <br />G <br />TRENCH DIMENSION X XYDS OF SOIL <br />DEPTH TO G.W.: FT. 7sLvLING METHOD <br />H <br />2 <br />HOURS SINCE DEWATERING: <br />0 <br />SAMPLE : <br />LLOTHER <br />LABORATORY: SAMPLERS NAME: <br />�F­CLOSURE IN PLACE MIXTURE: f VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />