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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE A/ ADDRESS CIT]�Tj <br /> S; VIC <br /> F �4v A ul A <br /> OWNER NAME Z <br /> j_ Al OWNER PHONE 0 s. 1 2 <br /> CONTRACTOR-G--' 0 7_ 6 CONT. PHONE <br /> ,R Z <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORDATE TANK if 3 9 <br /> R RINSED (Y& OD dg�AL- RINSE AMOUNT/ .-- <br /> 10 N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED YON) METHOD RJAMOUNT USED <br /> ' <br /> A <br /> P READING AT REMOVAL L.E.L. : .o 02: ) - <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) X00 o <br /> 0 <br /> N TANK CONDITION (GOOD, POOR LHOLES) 1/Z p)e <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) C4 <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A Mo A,11 <br /> N liq(> 0 do 77< 5 <br /> K +1 '.Jo <br /> of-D "Aj A10 0 0 <br /> SN SIZE 1EXCAVATIOx' 36) x YDS OF SOIL <br /> � <br /> lvu-1 Z= 4,2,C. <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P 1 . <br /> L i <br /> I �z/v' S,/-/- <br /> N <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: � L�_6 SAMPLERS NAME:M61t;,o 4 k6ld <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />