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PUBLIC HEAL"`k SERVICES -ENVIRONMENTAL HF&kTH DIVISION <br />SITE NAME <br />fADDRESS <br />CITY <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTOR <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVALCLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR <br />DATE <br />TANK # 39 <br />R <br />N <br />S <br />I E <br />V <br />A <br />RINSED (Y/N) METHOD RINSE AMOUNT <br />RINSATE DISPOSAL SITE <br />JIMANIFEST # OR OTHER <br />VAPORS PURGED (Y/N) METHOD AMOUNT USED <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: <br />02: <br />1 R <br />IICOMMENTS <br />C <br />0 <br />TANK MATERIAL (STEEL, <br />FIBERGLASS, <br />OTHER) <br />N <br />S <br />TANK CONDITION (GOOD, <br />POOR, HOLES) <br />I <br />T <br />PIPE MATERIAL (STEEL, <br />FIBERGLASS, <br />OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />A <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />EXCAVATION SIZE X X <br />YDS OF SOIL <br />M <br />P <br />L <br />I <br />G <br />P <br />I <br />P <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE <br />TRENCH DIMENSION X <br />X _YDS <br />OF SOIL <br />2 <br />0 <br />LOTHER <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />AMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE:VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />