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PUBLIC HEAQ SERVICES-ENVIRONMENTAL HUTH DIVISION <br /> SITE NAME GC /7l' t- JADDREss �3 /� ' fY' f' 14d CITY S-f D C.`�f � <br /> OWNER NAME OWNER PHONE <br /> 1 <br /> CONTRACTOR lqk. CONT. PHONE � it <br /> FIRE PERMIT <br /> `1 <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> { INSPECTOR , G DATE�'� `�}'�� TANKI 3 9 A3 <br /> R RINSED ON) METHOD' RIMS AMOIINT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> 4 E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD <br /> AMOUNT USED <br /> A <br /> P READING AT REMOVALL.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL TEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR HOLES) r'U 5 , <br /> S " ' ,o <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> i' <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE ` <br /> T <br /> A <br /> i S EXCAVATION SIZE X 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 Ij -7YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE:S fo c <br /> LABORATORY: SAMPLERS NAME: <br /> LLI <br /> i3 <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94,: , PROVIIE SITE MAP ' <br /> 4 u <br />