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PUBLIC HEi+.6TH SERVICES-ENVIRONKENTAL hieAl-T-11 DIVISION <br /> SITE NAME ADDRESS ( CITY <br /> OWNER NAME (OWNER PHONE <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT If <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 4 39 A3G ! '4� `F <br /> R RINSED (Y/N) METHOD RINSE AMOUNT QS <br /> feI <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (YIN) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 102 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATMUAL (STEEL, FIBERGLASS, OTHER) <br /> N TANK CONDITION (GOOD, POOR, OLES) r 4 5i of ¢ �i }� 2� all ltiBeG Gr <br /> S iT PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) 24 FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE IOBSERVATION SAMPLE <br /> T <br /> Acl 4M <br /> N <br /> K <br /> S EXCAVATION SIZE % X ( YDS OF SOIL <br /> A <br /> M DEPTH I SOIL TYPE OBSERVATION SALE r <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TR.mcH onmg5I0N X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING HETHOD <br /> A <br /> 2 J4 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: I SAMPL=S NAME: <br /> CLOSURE IN PLACE I HIiXTUR=: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />