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ffUBLIC HEOH SERVICES -ENVIRONMENTAL &LTH <br />SITE NAMED <br />ADDRESS 15 6% IJ41yi CITY = <br />OWNER NAME uyl%v,��J <br />I OWNER PHONE <br />CONTRACTOR r, G®5- J <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR � DATE yam`/ � TANK f 39 13S:2 ®� <br />R <br />I <br />N <br />S <br />E <br />V <br />A <br />RINSED ) METHOD ® RINSE AMOUNT <br />RINSATE DISPOSAL SI'Z'E <br />JIMANIFEST # �j"��`�l�/ OR OTHER <br />VAPORS PURGED METHOD Po_.4r AMOUNT USED <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: Q <br />02: <br />R <br />COMMENTS <br />C <br />0 <br />TANK MATERIAL--( T , FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOO , 00 HOLES) <br />T <br />PIPE MATERIAL, FIBERGLASS, OTHER) <br />,# FEET <br />PIPE CONDITION (GOO POOR, LES) <br />S <br />A <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE` <br />EXCAVATION SIZE X X <br />YDS OF SOIL <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />Ll <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />TRENCH DIMENSION 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: <br />SAMPLERS NAME: <br />[-CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />