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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME ka <br />ADDRESS <br />CITY L <br />OWNER NAMEN.. <br />OWNER PHONE # Zai <br />CONTRACTOR <br />CONT. PHONE # <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE 3[,8 % TANK # 39 <br />R <br />RINSED (DR)METHO <br />W Som <br />RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST OR OTHER <br />VAPORS PURGED (WN) METHOD AMOUNT USED 2� <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.a <br />02: 3 �o <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, POOR, HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />S <br />T_ <br />A <br />N <br />K <br />if <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />�6 ;# <br />Fr <br />nlWv '_ <br />EXCAVATION SIZE �X L41tL) X 13Ff <br />YDS OF SOIL �D <br />A <br />M <br />P <br />L <br />P <br />I <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />LI.Lf,f I- ' <br />I <br />N <br />G <br />P <br />E <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />H <br />2 <br />0 <br /># HOURS SINCE DEWATERING: <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 />