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PUBLIC HEA'H SERVICES-ENVIRONMENTAL HF'ALTH DIVISION <br /> SITE NAME G" �' S ' ADDRESSCITY <br /> o <br /> / <br /> OWNER NAME L v, S OWNER PHONE # <br /> CONTRACTORlz <br /> � CONT. PHONE � ���_ O'�' <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR —7/4&f441 DATE 311'311S TANK f 39 /fjt/2!j <br /> R RINSED LVN) METHOD G T RINSE AMOUNT J� 1 <br /> I <br /> N RINSATE DISPOSAL SITE gCv— 6fc�� <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED ) METHOD / �� /C/, AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, rPOOR HOLES) <br /> S <br /> T PIPE MATERIAL (#t� , IBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE #� <br /> T <br /> A -rv. tro41 sot a.stcr�o -:o r}_ <br /> N <br /> K <br /> S EXCAVATION SIZE -7 X -tZ- X YDS OF SOIL^JG f" 1`7 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE if <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> Ll TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 1 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: Ce�P'3 11y SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />