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PUBLIC HEAL`l"S SERVICES-ENVIRONMENTAL HE' TH DIVISION <br /> SITE NAME US [ADDRESS CITY S <br /> OWNER NAME TOWNER PHONE <br /> CONTRACTOR CONT. PHONE <br /> FIRE P TT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 4 39 �q� 6 � <br /> R RINSED (Y® METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED I N) [METHOD AMOUNT USED q6 dS <br /> A <br /> P READING AT REMOVAL L.E.L. : 4, 102 : s <br /> 0 <br /> R COMMENTS � . <br /> C TANK MATER-IAL (STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, _OOR, HOLES) <br /> S <br /> T PIPE MATERIP (STE FIBERGLASS, OTHER) I � FEET <br /> PIPE CONDITION (GOOD OOR, OLES) <br /> T DEPTH [ SOIL TYPE ( OBSERVATION [ SAMPLE # [ <br /> 12.5 S <br /> A <br /> N <br /> K <br /> I <br /> S 1EXCAVATION SIZES r )X YDS OF SOIL / <br /> A <br /> M DEPTH ( SOIL TYPE OBSERVATION ( SAMPLE r <br /> D P <br /> L I I <br /> I P <br /> N E <br /> G <br /> TRENCH DIXENSION 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 MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />