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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME dADDRESS <br />CITY <br />OWNER NAME 4,, <br />OWNER PHONE # rZ,y� _� <br />CONTRACTOR <br />CONT. PHONE # 20 3 <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR Q DATE `8\AA TANK if 39 <br />R <br />RINSED U)SN) <br />METHOD. , lJ RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />, <br />MANIFEST # r1ry136rIZkt') OR OTHER <br />VAPORS PURGED (�/N) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />02: [/ DI <br />O <br />R <br />COMMENTS <br />C <br />TANK MATERIAL EEL FIBERGLASS, OTHER) <br />O <br />N <br />TANK CONDITION (GOOD, ®O HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL, I OTHER) <br /># FEET ,P!T_ <br />PIPE CONDITION (GOOD, OR, HOLES) <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />13 <br />t s10 Cm �3 <br />S <br />EXCAVATION SIZE -qz- X- X <br />YDS OF SOIL 166E)A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />L <br />P <br />I <br />- <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION X X YDS OF SOIL <br />H <br />2 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />