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fftUBLIC HEA SERVICES -ENVIRONMENTAL &TH DIVISIOI <br />SITE NAME or I" do5 <br />ADDRESS ,5&//,5 tt)a&4�-o Rd. I CITY"340C <br />OWNER NAME S1110 0 A/ a4q dt> <br />OWNER PHONE <br />CONTRACTOR <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />-7 <br />DATE ® - ,U TANK 39 03 <br />R <br />I <br />N <br />S <br />I E JIMANIFEST <br />RINSED 6)N) METHOD RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />f OR OTHER <br />V <br />VAPORS PURGED ( IN) <br />METHOD P&y AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L. E. L. <br />02: <br />0 <br />LR J1 <br />COMMENTS <br />C <br />TANK MATERIAL(�STE�EL <br />FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION ((!SOD ,/POOR, <br />HOLES) <br />S <br />T <br />PIPE ERIAI<kSTE�EL, <br />FIBERGLASS, OTHER) <br />FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) IA444ZE 61 - <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />13 <br />ct I �77 <br />EXCAVATION SIZE <br />X X=YDS <br />OF SOIL <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />TRENCH DIMENSION <br />X X YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. TSAMPLING METHOD <br />HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: SAMPLERS NAME: <br />1CLOSURE IN PLACE MIXTURE: -7 VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />