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PUBLIC FERA SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME/h� _ ADDRESS y� s N/ CITY <br /> OWNER NAMEOWNER PHONE <br /> A✓ G✓. rl�� <br /> CONTRACTORD� G U61, sem/CONT. PHONE 7,09- �j 6 z - ti sem/ <br /> I <br /> FIRE PERMIT 3 1 66-V <br /> REMOVAL ✓ CLOSUR IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANS; P 39 SUS' p <br /> R RINSED a/N) ( SHOD RINSE A14OUN'T u <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S iE MANIFEST # OR OTHER <br /> LP <br /> VAPORS PURGED aM I METHOD (� u AMSOUNT USED -0 dl <br /> READING AT REMOVAL L.E.L. : Q <br /> COMMENTS LSZ G/ �1ar �6�z � <br /> C TANK MATERIAL _ FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (C-00D, 00 , HOLES) <br /> S <br /> T PIPE MATMZT-XL ( _ FIBERGLASS, OTHER) s FEET <br /> PIPE CONDITION (COCO, O HOLES) <br /> DEPTH SOIL '"?PE I OBSERVATION SAMPLE r <br /> T Z l c C �✓. <br /> A I S L <br /> N L <br /> R I <br /> I Al <br /> S EXCAVATION S=zz j z X /o/ X YDS OF SOIL 6 0 <br /> A <br /> M DEPTH SOIL =E OBSERVATION SAMPLE r _ <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DI=SION X X YDS OF SOIL <br /> DEPTH TO G.w'. : FT. SAMPLING METHOD <br /> H <br /> 2 J4 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPT <br /> LABORATORY:6GoA� T I SAMPLERS NAME: 7r-e-dP WSA" . <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />