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PUBLIC HEALTH SERVICES-ENVIRONMENTAL A�LTH DIVISION <br /> SITE NAMEADDRESS CITY <br /> OWNER NAME `n OWNER PHONE <br /> CONTRACTOR�h dr bl CONT. PHONE # <br /> FIRE PO <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR kt f fid— DATE TANK # 39 <br /> R RINSEDY N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGEDY N) I METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : ✓U 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL TEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, OOR, HOLES) rusted +P, tfact No V;-s r b l e. <br /> S bn <br /> T PIPE MATERIAL FIBERGLASS, OTHER) ejf FEET <br /> PIPE CONDITION (GOOD, DOOR, HOLES) raSte� Sh�hwK <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE #` <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE _�L 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 YDS OF SOIL <br /> DEPTH TO G. FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: S- Ooc K i 16 S p I <br /> LABORATORY:4,a0 / Gam SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />