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PUBLIC HVTH SERVICES -ENVIRONMENTAL F7ALTH DIVISION <br />SITE NAMEAyr l,y-7�"S <br />ADDRESS,,,,30 -' S, / Ic <br />CITX� 74a <br />OWNER NAME w; e- h / <br />OWNER PHONE #(��, p�'- 13 (, 7 <br />CONTRACTOR i�Ay b,tt <br />CONT. PHONE # <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR ISP 7 6> 4:- 6P S DATE,2aQ- y& TANK # 39 Z 11 <br />R <br />I <br />N <br />S <br />E <br />RINSED Y N) METHOD RINSE AMOUNT 350 <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR OTHER <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED ON) METHOD c, AMOUNT USED j03 46 j <br />READING AT REMOVAL L.E.L.: 02: <br />COMMENTS <br />C <br />0 <br />TANK MATERIALSTE FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION GOO POOR, HOLES), <br />T <br />PIPE MATERIAL STEEL FIBERGLASS, OTHER) <br /># FEET y <br />PIPE CONDITION (GOOD 00 , HOLES) <br />TD <br />DEPTH <br />SOIL TYPE OBSERVATION SAMPLE # <br />A <br />I <br />r LO ' ✓C_ <br />K <br />rr <br />1 Dr S" <br />' l - <br />S <br />EXCAVATION SIZE ja XX / O <br />YDS OF SOIL 7� <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />L <br />I <br />P <br />I <br />N <br />E <br />rE <br />G <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: 30 FT. <br />SAMPLING METHOD <br />H <br />2 <br />A' I <br /># HOURS SINCE DEWATERING: A/ A <br />0 <br />OTHER SAMPLE: Sf0C, N C2 .S, <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 />9r5 <br />)es <br />