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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME( <br />ADDRESS <br />35 �, l-1 oA <br />CITrY � <br />OWNER NAME C� ,� <br />OWNER PHONE <br /># 16 76V 2p Sd1 <br />CONTRACTOR E <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE <br />TEMPORARYCLOSURE <br />INSPECTOR DATE 9�� / 7 TANK # 39 oCO-0 2 8/C 6a s <br />R <br />I <br />N <br />S <br />E <br />RINSED Y METHOD <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR <br />RINSE AMOUNT <br />OTHER <br />V <br />VAPORS PURGED ON) <br />METHOD <br />AMOUNT USED./,TO <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />A_3 <br />02: /,2- <br />,20 <br />0 <br />R <br />COMMENTS <br />C <br />0 <br />TANK MATERIAL STEEL FIBERGLASS, <br />OTHER) <br />N <br />S <br />TANK CONDITION OD POOR, HOLES) <br />T <br />PIPE MATERIAL STE FIBERGLASS, <br />OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, 002R HOLES) <br />T <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />A <br />N <br />Z <br />K <br />S <br />EXCAVATION SIZE SQL X 50 X <br />I3 <br />YDS OF SOIL� w <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />P <br />P <br />L <br />I <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION 1.� X <br />2.0 X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SA MPLING 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 />