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SITE NAME ````1 ADDRESS c, -r CITY <br />' OWNER NAMEOWNER PHONE <br /> CONTRACTOR CONT. PHONE <br /> sus u�cc-. <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 39 <br /> f R RINSED (Y/N) METHOD RINSE AMOUNT <br /> r <br /> I N RINSATE DISPOSAL SITE <br /> S <br /> E I MANIFEST # OR OTSER <br /> V VAPORS PURGED (Y/N) METHOD. JAMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATS L (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL STEEL ' BERGLAS , OTHER) 0 FEET <br /> PIPE CONDITION (GOOD, OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE r <br /> T <br /> I <br /> I4 A <br /> N <br /> K I 1 <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE -0 <br /> P P ,� 7,l F a ,Z L <br /> - <br /> L I <br /> ' <br /> I P ' �r G� r <br /> N E <br /> E G <br /> TRENCH DIl'4ENSION �- X �_ X ZO YDS OF SOIL <br /> DEPTH TO G.W. : FT. ] SAMPLING METHOD <br /> H <br /> 2 ,} HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> ---[-' <br /> t <br /> LABORATORY,. ' SAMPLERS NAME: <br /> CLOSURE IN PLACE MIIXTtTRE= 7 VOLUME: <br /> f EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />