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SITE NAME �G <br />ADDRESS t CITY <br />OWNER NAME ® / <br />OWNER PHONE # <br />CONTRACTOR ®tel` <br />CONT. PHONE # C <br />FIRE PERMIT # v. <br />/9 <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR ' DATE Z/ TANK # 39 1�Zp <br />R RINSED (Y102 METHOD / RINSE AMOUNT �l <br />I <br />N <br />S <br />RINSATE DISPOSAL SITE _ <br />E <br />JIMANIFEST # OR OTHER <br />AV <br />P <br />O <br />1 R <br />VAPORS PURGED ) METHOD Y jrl:- AMOUNT USED <br />READING AT REMOVAL L.E.L.: 02: <br />COMMENTS <br />C <br />0 <br />TANK MATERIAL (OffEEL—D (EEL-DFIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, POOR HOLES) <br />T <br />_ <br />PIPE MATERIAL (STEEL, BERGLA OTHER) <br /># FEET 1 / cA6 <br />PIPE CONDITION (GOOD, , HOLES) <br />S <br />A <br />T <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />EXCAVATION SIZE ^6�E X "3 X ,Z <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 YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: <br />LABORATORY: P6MA =SAMPLERS NAME: <br />CLOSURE IN PLACEMI7 <br />XTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />