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SITE NAME � � '�- ADDRESS �17 ���r �� CITY <br /> ode <br /> OWNER NAME � �! OWNER PHONE (z' � GSL;` - ��-7-d <br /> CONTRACTOR CONT. PHONE # Q7 <br /> FIRE PERMIT Z7 , <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �'`�` DATE io1ig c'Z, TANK if 39 <br /> R RINSED (YM METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED jD <br /> A <br /> P READING AT REMOVAL L.E.L. : j� 02: -6 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STEEL,;FIBERGLASS, _OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD 'P68R, HOLES) <br /> T PIPE MATERIAL _STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD-POOR.; HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> TaG> a <br /> G <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE 6,Q�- X f X -� YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> iF_CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />