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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS�� �2l2a CITY <br />OWNER NAME <br />OWNER PHONE # C, S <br />CONTRACTOR-S.....CONT. <br />PHONE # Lp 6 <br />FIRE PERMIT # <br />REMOVAL\D _ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE 3 l8 <br />- TANK # 39 <br />R <br />RINSED ,&VN) METHOD pig e. �µ z <br />RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />E <br />V <br />MANIFEST # 0030-721C) OR OTHER <br />VAPORS PURGED ON) METHOD Z� AMOUNT USED zoo <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: d �D <br />02: op <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL 6TEFFIBERGLASS, OTHER) <br />O <br />N <br />TANK CONDITION (GOOD POO HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL < I ERG , OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, 00 HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />� w � <br />A <br />N <br />Gad <br />F GOib a <br />K <br />S <br />EXCAVATION SIZE L,HZX 141 x _L3 <br />YDS OF SOIL (C)Ov <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE # <br />P <br />P <br />rL a <br />L <br />I <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 />