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PUBLIC HEA* SERVICES-ENVIRONMENTAL H*TH DIVISION <br /> SITE NAME ADDRESS &4?0f 1' O�i CITY,5 /O <br /> OWNER NAME�' `fig `OWNER PHONE <br /> CONTRACTOR Z�t� I CONT. PHONE , <br /> FIRE PERMIT , I <br /> O CLOSURE _Y PLACE TEMPORARY CLOSURE <br /> INSPECTOR4. <br /> DATE JD-/ 7 TANK f 39 <br /> R RINSED (Y/N NETHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E 11MANIFEST , OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD // 14 AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : /� �. �� 02: <br /> O � <br /> R COMMENTS Old 9�6 ciz,;i �- <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) , FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPS (OBSERVATION SAMPLE <br /> T -f I 1 <br /> A <br /> K '� �orMe d K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION 1� _ SAMPLE <br /> P P _ <br /> L I SE <br /> P-Al <br /> I P _ _ <br /> GE r I oyx, ' <br /> TRENCH DIMENSION l ..c� , X , y X _ YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DENATERING: <br /> 0 <br /> OTHER SAMPLE: / <br /> LABORATORY:/'lG�C�1M hP�I hi7U f,G AMPLERS NAM:ljL �;'F <br /> CLOSURE IN PLACE HIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />