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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION / oGj <br /> S TE AME S D 6 ADDRESS ,0�.. A-(, L G ITY <br /> OWNER N ` OWNER PHONE /0 Z g <br /> L <br /> CONTRACTO,RL ( CONT. PHONE 'y3._ O Z' <br /> FIRE PERMIT # fJA <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR t^ DATE SANK # 3 9 <br /> GI <br /> R RINSED (Y`/�N OD - RINSE AMOUNT <br /> I !� <br /> N RINSATE DISPOSAL SITE 1"Av G Z ' <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED �rr\ -JL� AMOUNT USED <br /> Q <br /> A C J <br /> P READING AT REMOVAL L.E. 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL ((S,r FIBERGLASS, OTHER) �< <br /> O <br /> N TANK CONDITION �(GOODPOOR, HOLES) <br /> S / <br /> T PIPE MATERIAL, FIBERGLASS, OTHER) � FEET <br /> PIPE CONDITION (GOO POOR, HOLES) A. <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE z' <br /> T <br /> A f W� Ip Lt fl <br /> TR/Ij <br /> x � r 1 <br /> S EXCAVATION 4IZz 12X L_ X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. :_Z_Zl SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: <br /> SAMPLERS NAME: III G <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />