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PUBLIC HEALTH SERVICES-ENVIRONMENTAL 'TF.ALTH DIVISION <br /> SITE NAME t �� " ��' ADDRESS FZ� 5 « ��c' CITY <br /> OWNER NAME �" OWNER PHONE # <br /> CONTRACTORCONT. PHONE X33 <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOv� DATE za/� TANK # 39 <br /> R RINSED ®/N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED METHOD AMOUNT USED sL <br /> A <br /> P READING AT REMOVAL L.E.L. : j v 02: '7 w <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 00 HOLES) <br /> S <br /> T PIPE MATERIAL FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, OOR OLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T 135, SA Gnw v oOn� ., <br /> A v5v.t O,- a.9o%�o r-3- w <br /> N <br /> K <br /> S EXCAVATION SIZE .,2377 X X YDS OF SOIL wv <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> L. 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 PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />