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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE <br /> ADDRESS <br /> OWNER NAME; /J OWNER PHONE <br /> tl- 00s <br /> —6 - <br /> -7-7 <br /> CONTRACTOR CONT. PHONE f <br /> FIRE PERMIT # IJA <br /> REMOVAL_ T C3 <br /> CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE t/TANK # 39 <br /> R RINSED (Y& VMETHOD JAI, 46�F-,b�>,A RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> 12-1 MANIFEST # OR OTHER <br /> V VAPORS PURGED METHOD �e IV -Z,e <br /> I AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : Z o 02 <br /> 0 <br /> 1 R 11COMMENTS <br /> C TANK MATERIALST!Fj <br /> , FIBERGLASS, OTHER) Ifo <br /> 0 A <br /> N TANK CONDITIONVO , POOR, HOLES)Li <br /> PIPE MATERIAL ±TE!L) FIBERGLASS, 07FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) 21 <br /> DEPTH SOIL TYPE OBSERVATION I/. SAMPLE <br /> T <br /> A ah/. zz <br /> N o <br /> K <br /> S EXCAVATION SIZE X X 4&�Ds OF SOIL y <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPIfE <br /> P P — <br /> L I <br /> I P 4 <br /> N E <br /> v <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> H <br /> DEPTH TO G.W. : D FT! SAMPLING METHOD <br /> v I <br /> `�k�k <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> SAMPLERS NAME: <br /> LABORATORY: t/±=Vl—ce M A-/Z O f.'J <br /> ,F CLOSURE IN PLACE MIXTURE: -7 VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />