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PUBLIC HEALTOSSF-RVICES-ENVj--RONMENTAL MOTS& wwoo ".1 <br />SITE NAME G® G/ vo <br />ADDRESS ` G ,, r CITY <br />OWNER NAME 5® ®'� <br />I OWNER PHONE (y 3 33 - / 3 <br />CONTRACTORG <br />I CONT. PHONE # <br />FIRE PERMIT ZSSv�- <br />Z <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE?TANK 39/,P/-7,/ <br />R <br />RINSED ( ) I METHOD <br />--rAdkF RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE fa <br />S <br />E <br />JIMANIFEST <br />OR OTHER <br />V <br />A <br />VAPORS PURGED ) <br />METHOD / AMOUNT USED <br />P <br />0 <br />READING AT REMOVAL , L.E.L.: 102: <br />R <br />COMMENTS <br />C <br />TANK MATERIAL FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />T <br />FIPE MATERIAL (STEEL, <br />FIBERGLASS, OTHER) <br />FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />DEPTH SOIL TYPE <br />I OBSERVATION (SAMPLE ` <br />R <br />S <br />EXCAVATION SIZE <br />X X <br />YDS OF SOIL <br />A <br />M <br />DEPTH ISOIL TYPE <br />OBSERVATION TSSAMPLE, <br />P <br />P <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION <br />X X YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. SAMPLING METHOD <br />H <br />2 <br />a HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LJ - <br />LABORATORY: <br />SAMPLERS NAME: y <br />CLOSURE IN PLACE MIXTURE: <br />-T VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />