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PUBLIC HEALV"ERVICES-ENVIRONMENTAL HEALTH DIVISION <br />� - <br />SITENAME <br />ADDRESS �J CITY <br />llLl <br />OWNER NAME Ct JOWNER <br />PHONE <br />CONTRACTOR /J <br />CONT. PHONE` <br />FIRE PERMIT , <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE ��� TANK 39 <br />R <br />N <br />S <br />E 11MANIFEST <br />RINSED /N) METHODS',,��y RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br /># S /3 OR OTHER <br />V <br />A_Z <br />P <br />0 <br />R <br />VAPORS PURGED /N) <br />READING AT REMOVAL <br />COMMENTS <br />METHODAMOUNT USED a <br />61 <br />L.E.L.: 02: <br />C <br />TANK MATERIAL TEEL <br />FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, <br />POO , HOLES) <br />S <br />T <br />PIPE MATERIAL STE , <br />FIBERGLASS, OTHER) <br />If FEET <br />PIPE CONDITION (GOOD, <br />OOR HOLES) <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL E <br />OBSERVATION SAMPLE <br />u H <br />%6 <br />EXCAVATION SIZE <br />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 />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE ,# <br />TRENCH DIMENSION <br />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 SAMPLE: <br />--T <br />LABORATORY: <br />MPLERS NAME: <br />S <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />