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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAMEADDRESS G CITY <br /> OWNER NAME Ttr <br /> OWNER PHONE # <br /> CONTRACTORCONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL_A_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE l( TANK # 39 19' <br /> R RINSEDI) METHOD - RINSE AMOUNT <br /> I v <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y ) METHODLV <br /> AMOUNT USED d <br /> A <br /> P READING AT REMOVAL L.E.L. : d 7o 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, ITPRd HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> N j,� s t <br /> K <br /> S EXCAVATION SIZE 1,_frX _3JE�F'X L�Ar YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L IILM 4 ) <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 /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />