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PUBLIC HEALAERVICES-ENVIRONMENTAL HEA* DIVISION <br />SITE N <br />DRESS 7d�ojLz CITY <br />OWNER NAME Gvv (d <br />OWNER PHONE q - 330 b <br />CONTRACTOR F�gc� <br />CONT. PHONE , <br />Co`+ - -4sCc3 <br />FIRE PERMIT af <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR S DATE TANK ,1 39 1 6, 7% 0� <br />R <br />RINSED (_,N) <br />r METHOD <br />RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST O SS) OR OTHER <br />VAPORS PURGED (Y/N) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L..: <br />02: <br />O <br />R IICO14MENTS <br />C <br />TANK MATERIAL (STEEL, BER �,S'-; OTHER) N 1oLn,4` } q&,4 3tOi-c� <br />0 <br />N <br />TANK CONDITION (GOOD, POO , HOLES) <br />S <br />T <br />PIPE MATERIAL � FIBERGLASS, OTHER) If <br />FEET X <br />PIPE CONDITION (GOOD, 00 , HOLES) <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE , <br />i 3 l' t - <br />i4 Sewic� ) �t <br />EXCAVATION SIZE X 38,S X <br />YDS OF SOIL <br />A <br />M <br />P <br />I <br />N <br />P <br />P <br />E <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />G <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />LLOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />1 HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />