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PUBLIC HEALTH SERVICES-ENVIRONMENTAL 71VALTH DIVISION <br /> SITE NAME ADDRESS ��J GG L- CITY joq <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR j/ CONT. PHONE �7t�._ c <br /> FIRE PERMIT y" <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �� "� DATE /y/ TANK # 39 <br /> R RINSED (( I) METHOD RINSE AMOUNT y n <br /> I Tv'i+G <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> TRV VAPORS PURGED /N) METHOD /��'L G' AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : _ /� 02: L� <br /> 0 <br /> COMMENTS <br /> C TANK MATERIAL ( FG, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, q!TjF,? HOLES) <br /> S <br /> T PIPE MATERIAL(2�E� FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOO HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X y(, X i YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> 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. � ��'��' SAMPLERS NAME: <br /> CLOSURE IN PLACEMIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />