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PUBLIC HIOSERVICES-ENVIRONMENTAL 4W DIVISION <br />SITE NAME ��j <br />ADDRESS —7 CITY <br />OWNER NAME <br />IoWNER PHONE � - 2b1 <br />CONTRACTOR <br />ICONT. PHONE , '-'?®g <br />FIRE PERMIT a <br />I GyFD <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR ff DATE �' � TANK t 39 /�lJ <br />R RINSED N) METHOD o ��ah�Y RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />®/ <br />MANIFEST SF61,Y /3 OR OTHER <br />V <br />A <br />P <br />O <br />R <br />VAPORS PURGED /N) `METHODLo 2- 'D( l- AMOUNT USED <br />-7 !22 <br />READING AT REMOVAL L.E.L.: 2, 02: <br />CONSMENTS <br />C <br />TADIK MATERIALTE FIBERGLASS, OTHER) <br />O <br />N <br />TANK CONDITION (GOOD, P HOLES) <br />S <br />T <br />PIPE MATERIAL , FIBERGLASS, OTHER) <br />FEET <br />TP <br />PIPE CONDITION (GOOD/ -90-6k, HOLES) <br />S <br />T <br />A <br />N <br />DEPTH SOIL TYPE OBSERVATION ISAMPLE ,r f <br />1:43- lw-3 <br />T3- J <br />I i <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 />Ll <br />DEPTH SOIL TYPE JOBSZRVATION SAMPLE <br />1 <br />TRENCH DIMENSION X X YDS OF SOIL <br />LL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />14 HOURS SINCE DEWATERING: <br />j <br />OTHER SAMPLE: I <br />--7 <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE ! MIXTURE: P VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />