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PUBLIC HEAL-!(e SERVICES-ENVIRONMENTAL A& '4, DIVISION � � D r�^� <br /> 11- <br /> ke — CITY <br /> SITE NAME1441) '71 <br /> ADDRESS 2� <br /> 27 <br /> OWNER NAME OWNER PHONE <br /> CONTRA T �� ( CONT. PHONE q��j -3�� 1660 <br /> FIRE PERMIT !1f f} I <br /> REMOVAL x CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORG,t/ ,�.'✓i1-f <br /> DATE bT L�TANK ` 39 - <br /> ' RINSE AMOUNT <br /> R RINSED (Y% ) Z'HOD PIP /V <br /> I f <br /> N RINSATE DISPOSAL SITE fi%GK <br /> SOR OTHER <br /> E MANIFEST # <br /> USED <br /> V VAPORS PURGED (Ys/N) METHOD AMOUNT <br /> � �_ <br /> A5 02: <br /> P READING AT REMOVAL L.E.L. : <br /> O7i�-t� <br /> R COMMENTS �iS� <br /> C TANK MATERIAL (STEEL), FIBERGLASS, OTHER) Qa� <br /> OHOLES) <br /> N TANK CONDITION GOO , POOR, <br /> S - <br /> T PIPE MATERIAL (STEEL FIBERGLASS,f/ OTHER) FEET G� �Z COQ}l>Eli <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TV---:,E OBSERVATION SAMPLE" <br /> K _ <br /> �' X � YDS OF SOIL v� <br /> S EXCAVATION SIZE X J?S <br /> ASAMPLE " <br /> M DEPTH SOIL TYPE OBSERVATION <br /> P P <br /> L I i vv t� Ro W1�1• S , <br /> N E <br /> GYDS OF SOIL <br /> TRENCH DIMENS_ON X X <br /> DEPTH TO G.W. : FT• SAMPLING METHOD <br /> HH <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME• i"L'1 U r, <br /> CLOSURE IN PLACE i MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />