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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME1�a Cod <br />ADDRESS OUB r <br />CZT <br />OWNER NAME <br />OWNER PHONE #� <br />CONTRACTOR <br />CONT. PHONE Zdl 4 57 5 <br />FIRE PERMIT # <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE �a <br />9 TANK # 39 <br />R <br />RINSED ) METHOD (J <br />RINSE AMOUNT 3p <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST # 4C7:3 6VI21 CJ OR OTHER <br />VAPORS PURGED �) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: © -70 <br />02:CZ <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL STE , FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD 00) HOLES) <br />S <br />T <br />PIPE MATERIAL (STE FIBERGLAS , OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, OOR, OLES) <br />T <br />A <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />_ <br />k'sar l3 <br />Fr r - <br />N <br />Fr <br />K <br />S <br />EXCAVATION SIZE 4T- X _1_�LL X\3p <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />P <br />I <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />C L44v <br />I <br />P <br />N <br />G <br />E <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. 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 />