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P . a / DIVISION <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />I <br />ADDRESS <br />• , <br />i • PHONE <br />,CONTRACTOR 45;c�J <br />CONT4 PHONE <br />IFIRE PERMIT <br />REMOVAL. CLOSURE 114 PLACE TEMPORARY CLOSURE <br />�INSPECTOR <br />, DATE ,,,.• <br />• <br />• <br />RINSED (YIN) RINSE AMOUNT <br />RINSATE DISPOSAL <br />,READING •i • • <br />1 <br />• <br />MATERIAL ii► <br />FIBERGLASS, OTHER) <br />CONDITION iii <br />'i•, <br />',PIPE L (STEELi <br />FIBERGLASsfOTHER) <br />PIPE CONDITION00A <br />•i••r • <br />IMAM W -07,T fir; _MW- �M" <br />EXCAVATION SIZE 146 X,7 X 17 <br />YDSOF • <br />OBSERVATION <br />TRENCH DIMENSION <br />r OF • IL <br />r <br />DEPTH TOISAMPLING METHOD <br />HOURSr <br />•SAMPLE: <br />/• • <br />LABORATORY.,CLOSURE <br />IN PLACE <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />I <br />