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PUBLIC HEALTOSERVICES—ENVIRONMENTAL's DIVISION <br />SITE NAME /..®j,r jc::" -6 /v <br />ADDRESS CITY <br />OWNER NAME i' I <br />I OWNER PHONE <br />CONTRACTOR ✓� �� <br />CONT. PHONE <br />FIRE PERMIT` <br />REMOVAL )C CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR �G DATE -71J F/ - TANK f 3 9 �6-06Z.-q&- <br />4 <br />R RINSED /N) METHOD ®r RINSE AMOUNT '( <br />I-1 <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST OR OTHER <br />V <br />A <br />P <br />O <br />R <br />VAPORS PURGED (Y/N) METHOD 1p� ®�y� AMOUNT USED ✓ If <br />READING AT REMOVAL L.E.L.: �' 02: <br />COMMENTS <br />C <br />TANK MATERIAL f!�IBERGLASS, OTHER) <br />O <br />N <br />TANK CONDITION (GOOD 00 OLES) <br />S <br />T <br />PIPE MAT ( E FIBERGLASS, OTHER) <br />FEET <br />PIPE CONDITION (GOOD, CHOLES) <br />S <br />m <br />AAp <br />N <br />K <br />DEPTH SOIL TYPE OBS = ON (SAMPLE 24 <br />AIDSir <br />EXCAVATION SIZE e'x i X %aff <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 OBSERVATION SAMPLE <br />TRENCH DIMENSION X X YDS OF SOIL <br />LLOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />VOLUME: <br />CLOSURE IN PLACE I MIXTURE: 7 <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />