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PUBLIC HEAjW SERVICES -ENVIRONMENTAL J&LTH DIVISION <br />SITE NAME <br />ADDRESS ^ CITY <br />OWNER NAME ii <br />OWNER PHONE # (®� �" - j 3 <br />CONTRACTOR <br />CONT. PHONE # ---7//) <br />FIRE PERMIT # <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR t2 �, DATE Z,:� TANK` 39 j 3 <br />R <br />I <br />N <br />s <br />E <br />V <br />A <br />RINSED (Y/ METHOD RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />La <br />liMANIFEST # OR OTHER <br />VAPORS PURGED ) METHOD }� r�G AMOUNT USED / <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: �v <br />02: yd <br />R <br />COMMENTS <br />C <br />0 <br />TANK MATERI STS, FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GPOUf HOLES) <br />T <br />PIPE MATERIAL (STEEL, IBERG _ , OTHER) <br /># FEET <br />nHOLES) <br />PIPE CONDITION (GOOD <br />S <br />A <br />T <br />A <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />547V {- 6r� ® D Sa ®4 , . ®r< ®. <br />1, S <br />EXCAVATION SIZE,, X,:o <br />YDS OF SOIL <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />1JL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />-T- <br />LABORATORY: SAMPLERS NAME:' -31 PE <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />