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PUBLIC HEAzi'H SERVICES-ENVIRONMENTAL ham. LTH DIVISION <br /> SITE NAMEADDRESS, $ J CITY S D <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR S�IOCL[��' CONT. PHONE # <br /> FIRE PERMIT *4 n <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 4t cll R- DATE f (� TANK 1 39 <br /> R RINSED (YO, METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED !2x) METHOD R AMOUNT USED <br /> A <br /> P READING AT REMOVAL L. E.L. : 02 : <br /> R COMMENTS 1 b gyp, d&u , <br /> C TANK MATERIALSTEEL IBERGLASS ) �SfZr.L w/��IAF f <br /> O <br /> N TANK CONDITION (GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL STEEL FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION OD POOR, HOLES) <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 <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 DEWATERING: <br /> 0 <br /> OTHER SAMPLE: C H - Sf6G <br /> LABORATORY: 0 /oJ�s SAMPLERS NAME67/ � <br /> CLOSURE IN PLACE XTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />