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PUBLIC HEALTH SERVICES-ENV7RCNM_ENTAL HEALTH DIVISION <br /> SITE N ADDRESS lowCITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TMIPGRARY CLOSURE <br /> INSPECTOR DATE TANK 4 39 () i?) <br /> R BINS ( IN) I L�THOD RINSE AMOUNT <br /> I <br /> N RINSA DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED Y N) 1,4. .THOD AMOUNT USED < <br /> A <br /> P READING AT REMOVAL L.E.L. : 7361 02: < O/o <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL TEE) FIBERGLASS, OTHER <br /> j <br /> 0 <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAE. (STEEL, FIBERGLASS, OTHER) I # FELT <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH ( SOIL TYPE OBSERVATION SAMPLE <br /> T QD <br /> 2 <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 II l <br /> L I <br /> I P <br /> N E <br /> G <br /> Li <br /> TRENCH DIMENSION X X ( YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 if HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE LUME: <br /> 2H 23-0043 (:LF'V 2/23/94) PROVIDE SITU MAP <br />