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PUBLIC HEAT,TH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAMEDaf40`F8 ADDRESS 3 Q g s. �� CITY <br /> OWNER NAME fj4Va� OWNER PHONE <br /> CONTRACTO - CONT. PHONE <br /> FIRE PERMIT $ q,5 / <br /> REMOVAL_ CLOSURE IN PLACE �G TEMPORARY CLOSURE <br /> INSPECTOR Ufilv DATE if tea{✓✓ s TANK # 3 9 <br /> R RINSED (01N) METHOD- RINSE AMOUNT f <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (ij N) ( METHOD �� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : g 02: <br /> R COMMENTS <br /> C TANK MATERIAL (STE , FIBERGLASS, OTHER) <br /> 0 Soyva� <br /> N TANK CONDITION (GOOD, (POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD( POO HOLES) Lo eBkAca�. OyL' <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N } <br /> K <br /> S EXCAVATION SIZE C2_ X X _ YDS OF SOIL <br /> A 11 <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 S HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: C I /' <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />