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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS 3 S 3 S f-, <br />CITY <br />n // <br />OWNER NAME Lac ci�✓� <br />OWNER PHONE 9 <br />CONTRACTOR / v v <br />CONT. PHONE #�6? Q <br />FIRE PERMIT # 7QC <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />p <br />INSPECTOR DATE j�7 TANK # 39 f6GI��a3 (16x <br />- <br />R <br />I <br />RINSED Y ) METHOD RINSE AMOUNT �75 <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST # OR OTHER <br />V <br />VAPORS PURGED 6)N) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL L.E.L.: O, Z 02: 2.1 <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL( TEEL, FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION GOOD, POOR, HOLES) <br />S <br />T <br />PIPE MATERIAL((STE FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />A <br />F <br />N <br />K <br />7-3- W <br />It <br />S <br />EXCAVATION SIZE 2,�5 X 50 X ( 3 <br />YDS OF SOIL 9 <br />.3 <br />A <br />M <br />DEPTH <br />SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION tX 2.O X /50 <br />YDS OF SOIL <br />DEPTH TO G.W.: 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 />