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PUBLIC &TH <br />SERVICES-ENVIRONMENTX&ALTH DIVISION <br />SITE NAME ' 6JADDRESS/-,7/0 <br />;5. CITY S M <br />OWNER NAME/ % <br />I OWNER PHONE 1 zv q - .Syf_3 __3.Z,4 <br />CONTRACTOR N a/ l , c <br />CONT . PHONE 516--37Z,- / iii gS <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR �(DATE 6-//-y.6 TANK # 39 <br />R RINSED ®/N) METHOD RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />E <br />MANIFEST OR OTHER <br />V <br />VAPORS PURGED ) IMETHOD AMOUNT USM -30V <br />A <br />P <br />READING AT REMOVAL L.E.L.: <br />02: <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL STE , FIBERGLASS, OTHER) <br />O <br />N <br />S <br />TANK CONDITION ( GOOD , OOR HOLES) <br />T <br />PIPEMATERIAL (STEEL, FIBERGLASS, OTHER) Ix FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) 14v,4 no <br />DEPTH IS01-L TYPE (OBSERVATION (SAMPLE ,# <br />T& <br />N- <br />�- <br />K <br />I i <br />S <br />EXCAVATION SIZE. O�L X jLr X <br />YDS OF SOIL <br />_J/_/ <br />A <br />M <br />DEPTH (SOIL TYPE OBSERVATION SAMPLE n <br />P <br />P <br />i <br />L <br />I <br />I <br />P <br />I <br />N <br />E <br />I <br />G <br />I <br />TRENCH DIMENSION X X YDS OF SOIL <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />H <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />I OTHER SAMPLE: <br />LABORATORY: ,¢. <br />SAMPLERS NA -E : , <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />