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PUBLIC HrXLTi' IERvICES-ENVIRONMENTAI r -H DIVISION <br /> SITE NAME/,,,/,�y� ADDRESS 3pzj >c, �� � CITYGgo= <br /> OWNER Y� OWNER PHONE <br /> CONTRACTO$.-,/ � CONT. PHONE # 36g - 6/ 7 <br /> alz- <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN <br /> IN PLACE TEMPORARY CLOSURE <br /> ). <br /> INSPECTOR Z,-- eE DATE / moi TANK # 39 <br /> R RINSED (Y/N) METHOD RINSE AMOUNT <br /> I <br /> FE <br /> RINSATE DISPOSAL SITE <br /> MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S - <br /> T PIPE MATERIAL (STEE , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <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 /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: p� a� AA,85 SAMPLERS NAME: ��F✓J I D� <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />