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PUBLIC HEAL'T"f` SERVICES-ENVIRONMENTAL HEPeTH DIVISION <br /> SITE NAME Qo"H (ADDRESSS. i2 CITY FO <br /> OWNER NAME ( OWNER PHONE <br /> CONTRACTOR 2d �t2 CONT. PHONE } gqqD <br /> FIRE PERMIT r c �X/ <br /> REMOVAL_-V K-CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK P 39 1:21/2 <br /> R RINSED (Y®) I METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED dyN) (METHOD (AMOUNT USED / C <br /> A (o <br /> P READING AT REMOVAL I L.E.L. : 102 : <br /> O 117 <br /> R COMMENTS b <br /> C TANK MAT (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERSp.L (STEL , FIBERGLASS, OTHER) FEET y� <br /> PIPE CONDITION (GOOD, POOR HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> TSNA <br /> A <br /> N r, <br /> K <br /> SEXCAVATION SIZE � jX /d.Se YDS OF SOIL <br /> A 166 <br /> M 11 -DEPTH ( SOIL TYPE OBSERVATION SAMPLE <br /> P PI I <br /> L I aJo <br /> I P L& I I I <br /> N E <br /> G <br /> TRENCH DIMEN SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. ( SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />