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PUBLIC HEA" 3 SERVICES-ENVIRONMENTAL H- ',TH DIVISION <br /> SITE NAM " ADDRESS F, > i C 1= CITY <br /> E c <br /> OWNER NAME `` OWNER PHONE # • ', <br /> CONTRACTOR t-Nle L CONT. PHONE # _ <br /> FIRE PERMIT #�p9tno33 <br /> REMOVAL K CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ��o Shic,t�� DATE�? TANK # 39 <br /> R RINSED 0/N) METHOD T,4l Q"KA RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S l J' C <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (YIN) METHOD 15O #�� �� AMOUNT USED I's-n= <br /> A <br /> P READING AT REMOVAL L.E.L. : c� 5 02 : 8 <br /> 0 <br /> R COMMENTS t r_L I� -}� o UZ <br /> C TANK MATERIAL STE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAL TEEL FIBERGLASS, OTHER) # FEET �U <br /> PIPE CONDITION (GOOD,QQO QOLES <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <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 S V S CATSV--S, P-O <br /> L I <br /> I P No Codon P- 1 <br /> N E 'q Y2 � � Odor to fAct <br /> G 'R w Oder t. 14 4 <br /> TRENCH DIMENSION 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:(,,,,, Com( SAMPLERS NAME: F,,c �,Lrj_ <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />