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PUBLIC H:`.TH SERVICES-ENVIRONMENTAL �ALTH DIVISION <br /> SITE NAMEADDRESS CIT`js <br /> AA <br /> OWNER NAME d MWMC� OWNER PHONE ig CP - 93,2-q <br /> CONTRACTOR C CONT. PHONE # <br /> FIRE PERMIT D_ a <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE ' TANK {6 39 <br /> R RINSED (Y N) METHOD '�) RINSE AMOUNT <br /> 2 <br /> N RINSATE DISPOSAL SITE I oj�k5V v p I cp <br /> S <br /> E MANIFEST ol �� ( OR OTHER <br /> V VAPORS PURGED (Y)N) METHOD ' IAMOUNT USED 25 <br /> A <br /> P READING AT REMOVAL L.E.L. : CJ 02: ND <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD POO , HOLES) cD� <br /> S <br /> T PIPE MATERIAL STEEL, IBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE 54 <br /> A I Y <br /> N It CD ov) 03S <br /> K <br /> S EXCAVATION SIZE XX g YDS OF SOIL too <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 DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> x <br /> 2 1 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 />