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PUBLIC HE1�TH SERVICES-ENVIRONMENTAL i,rnr,Ta DIVISION <br /> SITE NAME (ADDRESS ( CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR CONT. PHONE it <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR B(+! DATE (ate( q ' �ITANX s 39 1 3 <br /> R RINSED (Y/N) METHOD R_TNSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : Q 02 : <br /> 0 <br /> R COMMENTS <br /> C TAMC MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> Sr i <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTMP <br /> H SOIL TYPE ( OBSERVATION ( SALE F <br /> T I I <br /> A K LASI <br /> N � <br /> K <br /> I <br /> S EXCAVATION SIZE — X — x — YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE T <br /> P P <br /> L I i <br /> I P <br /> N E <br /> G Ll � <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING HETHOD <br /> H <br /> 2 0 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOL=: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />