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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME, <br />ADDRESS l <br />CITY <br />OWNER NAME& <br />OWNER PHONE <br />CONTRACTOR t.CONT. <br />PHONE # <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE rJ TANK # 39 <br />R <br />RINSED Y) <br />METHOD S <br />RINSE AMOIINT <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST # O2 /b OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED (Y ) METHOD AMOUNT IISID Z� <br />READING AT REMOVAL L.E.L.: Do7p 02: (D% <br />COMMENTS <br />C <br />TANK MATERIAL lgeE FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, 00 , HOLES) <br />S <br />T <br />PIPE MATERIAL (STE BERGLASS, THER) <br /># FEET <br />PIPE CONDITION (GOOD, 00 HOLES) <br />S <br />T <br />N <br />K <br />DEPTH (SOIL TYPE OBSERVATION SAMPLE # <br />l3 o D2_ \ <br />- ndCC2�_ <br />EXCAVATION SIZE XI w Lei X 13��� <br />YDS OF SOIL l Ooo <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />L <br />I <br />N <br />G <br />P.� <br />I <br />P <br />E <br />a - '� <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 />CLOSIIRE IN PLACE <br />MIXTCTRE. <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />