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PUBLIC HE; 7H SERVICES-ENVIRONMENTAL ILTH DIVISION <br /> SITE NAME- CITY <br /> CITY <br /> ��I� ` -^'Y:r nr <br /> OWNER NAME „ OWNER PHONE # ✓rte <br /> CONTRACTOR� , CONT. PHONE # 52� <br /> FIRE PERMIT # k; o <br /> REMOVAL`� p0 <br /> f1^j CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED (Y/N) METHOD. RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) METHODAMOUNT USED->< <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> O _ <br /> R COMMENTS / <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) , <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) _ J <br /> S -, <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) , <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <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 /> L I i �� - -1- Jc i� <br /> I P , cam. C rl o,r <br /> N E <br /> G <br /> Li 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 A , iSAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: — VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />