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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME d � � `- <br />ADDRESS 6_0= <br />CITY <br />OWNER NAME <br />OWNER PHONE # <br />CONTRACTOR( <br />CONT. PHONE # 4 <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE 3 i8 $ TANK # 39 <br />R <br />RINSED 1&N) <br />METHOD �lM �r WL} t4, <br />RINSE AMOUNT 3 d <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST # Qna Or72ib OR OTHER <br />VAPORS PURGED (DN) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: U°�� <br />02: [4 c, <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL TE , FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, O R HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL, ERG S, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD 00 HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />S <br />T <br />A <br />N <br />K <br />cm\4n-'7_ 'T ( 1 1 3 <br />t i %1 <br />Fr 15 <br />EXCAVATION SIZE L�Z X lµ1 X�_ <br />YDS OF SOIL toon <br />A <br />M <br />P <br />L <br />P <br />I <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />„ a <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SAMPLING 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 />