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PUBLIC HEAI- E SERVICES-ENVIRONMENTAL HEATH DIVISION <br /> SITE NAME V (ADDRESS (oqI EC1 W �tllCITY11 1S <br /> OWNER NAME&ato Pakwcod <br /> I OWNER PHONE ' Zol -6132-4 7 a- <br /> CONTRACTOR9h"•5V ' (CONT. PHONE at Z <br /> FIRE PERMIT <br /> REMOVAL_>C CLOSURE LV PLACE TEMPORARY CLOSURE <br /> INSPECTOR Q DATE TANK 1 39 (0 DZ <br /> R RINSED Y N) 2r�S' HOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITS I n&t6 'Ytd s ,^ j( Q Oil <br /> S � V <br /> E MANIFEST Jq 1)CtO ( OR OTHER <br /> V VAPORS PURGED (9N) (METHODAMOIINT USED 12�_I�Ib <br /> A <br /> P READING AT REMOVAL I L.E.L. : 119 <br /> 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STF , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, (0OR, LES) <br /> S <br /> T PIPE MATERIAL STz IBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, OOR, HOLES) <br /> DEPTH ( SOIL =- (OBSERVATION ISAMPLE <br /> T IloamI ( r <br /> A IS - ?� r r oZs <br /> N I <br /> ii u <br /> K <br /> I <br /> S EXCAVATION SIZE X _3_ X $ YDS OF SOIL ZC <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 D:-�SICH X X IYDS OF SOIL, <br /> DEPTH TO G.W. : FT. SAMELNG METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: I SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />