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NAME <br />ADDRESS CITY <br />-JZSITE <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTORAl <br />,C;J$,r <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVALO CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR 4;2-�/ J4 DATE 71L TANK 1 39 '31 J <br />R <br />RINSED qVIN) METHOD,—�t,,W RINSE AMOUNT ,(O <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />IMANIFEST OR OTHER <br />VAPORS PURGED-JIP-It) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L. E. L. <br />02: <br />0 <br />COMMENTS <br />C <br />TANK MATERIAL (q!EEL FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOODFiZ7 HOLES) <br />S <br />PIPE MATERIAL .pJtMM�SS� OTHER) <br />FEET <br />PIPE CONDITION (GOO, , OLES) <br />S <br />T A <br />DEPTH SOIL- TYPE OBSERVATION SAMPLE <br />'57 olr-4v -r- 3 - 4-'- <br />EXCAVATION SIZE 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 />"I <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER AMPLE: <br />LABORATORY: <br />T SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />