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PUBLIC HEAT -'q SERVICES–ENVIRONMENTAL H''LTH DIVISION <br />SITE NAME <br />ADDRESS <br />CITYS <br />OWNER NAME 4yAOWNER <br />PHONE <br /># i (o3 <br />CONTRACTOR /J' <br />v <br />CONT. PHONE <br /># — <br />FIRE PERMIT # <br />3 <br />REMOVAL CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR L, T,DATE <br />TANK <br />R <br />RINSED ( /N) METHOD_ _ <br />RINSE AMOUNT �02 <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST # OR <br />OTHER <br />V <br />A <br />P <br />R <br />VAPORS PURGED (YIN) METHOD <br />READING AT REMOVAL L.E.L.: <br />COMMENTS � <br />AMOUNT USED j <br />" <br />02: <br />C <br />TANK MATERIAL STEEL FIBERGLASe, <br />OTHER)D s�1F�tSuu e <br />N <br />TANK CONDITION (GOODPOOR HOLES) <br />�(( p -, P NO VM � A <br />S <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, <br />OTHER) # FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />T <br />A <br />N <br />K <br />S <br />1EXCAVATION SIZE :R'Z X yg,'X <br />_4L <br />YDS OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />P <br />P <br />L <br />I <br />I <br />N <br />P <br />E <br />G <br />TRENCH DIMENSION 'n_ X <br />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: <br />LABORATORY:(jw <br />SAMPLERS NAME:FA am u/ <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />%fj <br />