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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME Jha� _ ADDRESS I15 S dIv--( 'j'7 CITY pGcK /u. <br /> OWNER NAME AA OWNER PHONE # !J�_ rj �,1- 6 7 0 Z <br /> L ✓ CONw 6 z - y �/CONTRACTOR <br /> FIRE PERMIT <br /> REMOVAL, V1 CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 SC:).Lj O�Z 0 Z <br /> R RINSED Q/N) METHOD �� �� RINSE AMOUNT { <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PIIRGIDQY/N) METHOD AMOUNT USED SSS doj+ L <br /> A �u <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS or r <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, Z2O HOLES) ksP <br /> S <br /> T PIPE MATERIAL ( FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, C00:0, LES <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> Ti <br /> A <br /> N S s <br /> EXCAVATION SIZE — X X // ' YDS OF SOIL /&V Yds <br /> M DEPTH SOIL T°PE OBSERVATION SAMPLE # <br /> P P 3 , z <br /> L I <br /> .3 <br /> 1 <br /> I P � o <br /> N E S <br /> G <br /> TRENCH DIMENSION X ? X ? YDS OF SOIL ? ? 7 <br /> DEPTH TO G.A. : FT. SAMPLING METHOD <br /> x <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: a <br /> LABORATORY:, e �� SAMPLERS NAME:-F!'ecr -S-+Y+w• <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EY 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />