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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME Cb <br />ADDRESS <br />CI <br />OWNER NAME C�OWNER <br />PHONE <br />CONTRACTO <br />CONT. PHONE # CZOo) <br />FIRE PERMIT # <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTORSE� <br />DATE TANK # 39 <br />R <br />RINSED (5/N) <br />METHOD-- uJ RINSE AMOUNT O <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST OR OTHER <br />VAPORS PURGED N) METHOD LGa AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: �]b <br />02: <br />O <br />R <br />COMMENTS b F,JG I- <br />C <br />TANK MAT STE , FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, e!04>HOLES) <br />S <br />T <br />PIPE MATERIAL (STE=,EziBERGLAS OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />S <br />Tr' <br />A <br />N <br />K <br />- T 1 <br />F <br />1 F <br />EXCAVATION SIZE q )K J.(L) X jjL,� <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />p <br />I <br />DEPTH SOIL TYPE OBSERVATION SAMPLE if <br />o u <br />I <br />I <br />P <br />N <br />G <br />E <br />TRENCH DIMENSION X 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 />