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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME`,� <br />ADDRESS <br />CITY —` <br />OWNER NAME El <br />OWNER PHONE <br />if <br />CONTRACTOR co <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVAL_ CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR <br />DATES JqR <br />TANK 39 <br />R <br />I <br />N <br />S <br />E <br />RINSED 6)N) METHOD�� W RINSE AMOUNT 3 <br />RINSATE DISPOSAL SITE <br />MANIFEST OR OTHER <br />V <br />A <br />P <br />O <br />R <br />VAPORS PURGED 41YN) METHOD <br />READING AT REMOVAL L.E.L.: fl <br />COMMENTS <br />AMOUNT USED 1 <br />p� <br />02: /f/C <br />C <br />TANK MATERIAL TEEL, FIBERGLASS, <br />OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, 00) HOLES) <br />S <br />T <br />PIPE MATERIAL (STE <br />) <br />.4 FEET Z a <br />PIPE CONDITION (GOOD HOLES) <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />S <br />T <br />A <br />N <br />K <br />it <br />Fr We. <br />Prcr <br />C <br />EF <br />I <br />EXCAVATION SIZE 4t X (41 X <br />YDS OF SOIL CCL <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE <br />P <br />P <br />414 <br />L <br />I <br />I <br />P <br />N <br />G <br />E <br />TRENCH DIMENSION X <br />X <br />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 <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />