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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESSI� < tr <br />CITY <br />OWNER NAME (� <br />OWNER PHONE <br />Sr - ZOs� <br />CONTRACTOR 6 £ <br />CONT. PHONE <br />wC?, 756 • OZ6 <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR <br />DATE <br />TANK # 39 OD -D /Q�P,Q <br />R <br />I <br />N <br />S <br />E <br />RINSED ) METHO <br />RINSATE DISPOSAL SITE <br />MANIFEST OR <br />RINSE AMOUNT <br />OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED &N) <br />READING AT REMOVAL <br />COMMENTS <br />METHOD <br />L.E.L.: <br />AMOUNT USED!3Q# <br />�.� 02: -7•� <br />C <br />0 <br />TANK MATERIAL STEEL, <br />FIBERGLASS, <br />OTHER) <br />N <br />S <br />TANK CONDITION ( OOD <br />POOR, HOLES) <br />T <br />PIPE MATERIAL ( T , <br />FIBERGLASS, <br />OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, <br />POOR HOLES) <br />T <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE <br />A <br />N <br />Z <br />K <br />v <br />n <br />S <br />A <br />EXCAVATION SIZE Z5 X 50 X <br />1_�) <br />YDS OF SOIL `L 3O0 3 <br />M <br />P <br />P <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE # <br />L <br />I <br />I <br />P <br />Od-eLa <br />rt -� <br />N <br />E <br />G <br />TRENCH DIMENSION <br />)•S X X ISO <br />YDS OF SOIL <br />DEPTH TO G.W.: J�0 FT. <br />SAMPLING METHOD <br />H <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />