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PUBLIC HEP' 'H SERVICES-ENVIRONMENTAL H LTH DIVISION <br /> SITE NAME I ADDRESS CITY`S <br /> OWNER NAME C 5 (OWNER PHONE # <br /> CONTRACTOR f U (CONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL_ CLOSURE I—DI PLACE TEMPORARY CLOSURE <br /> INSPECTOR c DATE r - 'TANK # 39 :5 <br /> R RINSED (Y/* OD N I v RINSE AMOUNTS60� <br /> N RINSATE DISPOSAL SITE N <br /> S <br /> E MANIFEST # N /a OR OTHER <br /> V VAPORS PURGED (Y/6) IMETHOD A,1,4 -7'I lled AMOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : /02 : <br /> R COMMENTS <br /> C TANK MATERIALTEEL' IBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, OLEO <br /> S <br /> T PIPE MATERIAL STE FIBERGLASS, OTHER) # FEET �a u/urr <br /> PIPE CONDITION (GOOD, POOR, HOLES) _26'w�c 0, t <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T illD.$ <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DcRATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: /4 SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> Revised Date 7/15/97 23 CCR UST Regs May 5, 1994 PAGE of <br /> PHS=(9/97) <br />