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mmlkL <br />SERVICES -ENVIRONMENTAL TH DIVISION <br />SITE NAME 6 / <br />ADDRESSI-,710 CITY <br />OWNER NAME ( /we.. <br />OWNER PHONE # zv c1- s�3 -3 z <br />CONTRACTOR , �y, -y� tel, <br />CONT. PHONE` 9/6--37Z- ! <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR �(^'�.� DATE TANK ,# 3 9 / ( 2 <br />R <br />RINSED Y N) METHOD <br />RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST if C S S'/ ?.-.3 OR OTHER <br />V <br />VAPORS PURGED /N) I METHOD 021 -,U— AMOUNT USED cSD l ba <br />A <br />P <br />c <br />READING AT REMOVAL L.E.L.: 102: /Y70 <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL TE FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, ® , HOLES) I � <br />S <br />f <br />T <br />PIPE TL. (STEEL, FIBERGLASS, OTHER) FE ET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />DEPTH (SOIL TYPE (OBSERVATION (SAMPLE <br />T <br />� <br />s - <br />s ® -- I <br />N <br />S <br />EXCAVATION SIZE ` X -3 Z.' X // ( <br />YDS OF SOIL / -3 <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE , <br />P <br />P <br />I ! <br />L <br />I <br />I <br />P <br />I I <br />N <br />E <br />G <br />TRENCH DIMENSION X X `YDS OF SOIL <br />DEPTH TO G.W.: FT. (SAMPLING M_ETH0D <br />H <br />2 <br />j HOURS SINCE DEWATERING: <br />0 <br />i <br />OTHER SAMPLE:LL <br />LABORATORY: <br />SAMPLERS NAME <br />CLOSURE IN PLACE ( MIXTURE: I VOLUME: � <br />F -H 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />