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PUBLIC HV,-,TH SERVICES -ENVIRONMENTAL T'F.ALTH DIVISION <br />SITE NAME t:,Pll 195 <br />ADDRESS ,�(05 / <br />CITY ifkz7yt <br />OWNER NAME J�'e r-tj, 61'a / P& <br />OWNER PHONE # <br />CONTRACTOR R f M C 0 fU <br />CONT. PHONE # <br />FIRE PERMIT # q6 _� 7 <br />REMOVA , CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR & _6L- DATE TANK # 39 S y�Q 3 Z5 <br />R <br />RINSED (Y ) <br />METHOD <br />RINSE AMOUNT <br />I <br />N <br />RINSATE DISPOSAL SITE TANK 1-f,414 Lc b Uy <br />S <br />E <br />V <br />MANIFEST # OR OTHER <br />VAPORS PURGED (Y N) METHOD AMOUNT USED <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: ' <br />02: 3Li <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERI (STE FIBERGLASS, OTHER) 7-4e/K 3 f f vv uii <br />0 <br />N <br />TANK CONDITIO GPOOR, HOLES) <br />S <br />T <br />PIPE MATERI (S�'FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, OOR HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />_ <br />A' <br />A <br />cl p i- T <br />N <br />�D <br />K <br />S <br />EXCAVATION SIZE LX _L# XYDS <br />OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />P <br />P <br />L <br />I <br />_ <br />I <br />P <br />_ <br />N <br />E <br />G <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:SfD` r� 4 <br />I� <br />LABORATORY: JdJ5L/a bora d <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />rP= Tlflt)KAt <br />13oPinr Ito le. <br />