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PUBLIC HEALTH "rTH SZRiVICES-ENVgtONXENTAL HEALTH DT_VISION <br />(SITE NAMEAr <br />�ADDRESsl313 C, C'1kah,ly <br />(`'I�Sfnc <br />(OWNER NAME <br />(OWNER PHONE <br />CONTRACTOR <br />(CONT. PHONE P <br />FIRE PERMIT r <br />REMOVAL X CLOSURE IN PLACE TE'TORA_RY CLOSURE <br />g <br />INSPECTOR / DATE aQ� I TANK r 39 <br />R <br />RINSED (Y/N) <br />TGOD <br />I RZXSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST OR OT= <br />V <br />VAPORS PURGED (Y/N) (METHOD <br />IAMCUNT USED <br />A <br />P <br />READING AT REMOVAL L.E.L.: <br />02: <br />0 <br />R <br />COMMENTS <br />C <br />TANX VAT T STEED FIBERZG ASS, OTHER) p <br />0 <br />N <br />TANK CONDITION (GOOD, POOR, HOLES) 4 IVA /oi <br />S <br />i T <br />PIPE MATERIAL (STEED, FIBERGLASS, OTHER) <br />s Fes^ <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />S <br />T <br />A <br />N <br />E <br />DEPTH SOIL TYPE (OBSERVATION ISAaMPLE r <br />I I I <br />I I <br />I I I <br />I I I <br />EXCAVATION SIZE_ I % YDS OF SOTS, j <br />11 <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE (OBSERVATION (SAMPLE r <br />I u I <br />I I <br />I i, <br />T7---NC3 DL�_...t'YSION % X YDS OF SO_ II <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />i <br />s HOURS SINCE DEWA'r'E.RIPiG: <br />OTH..x'R SAMPLE: <br />LABORATORY: ( SAS*?, -RE YANfZ : <br />CLOSLZ IN PT_.ACE <br />I K::{^JRE: <br />I 7CL=u : <br />D.= 23-0043 (=7 2/23/94) PROVIDE SITE V-A.? <br />