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PUBLIC H-1= SERVICES-ENVIRONMENTAL =H DIVISION <br /> SITE NAME7iO ADDRESS �5a�7j_ U CITY <br /> OWNER NAME OWNER PHONE #�z ) 23Jf Z✓LD <br /> CONTRACTOR g-1w-1115 CONT. PHONE <br /> FIRE PERMIT # <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE J z,- G7,F TANK # 39-:! US-U49� <br /> RRINSED LT N) METHOD--j;r RINSE AM f 3v <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED CPN) METHOD AMOUNT USED 5V <br /> A <br /> P READING AT REMOVAL L.E.L. : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOt��sNax, HOLES) <br /> S <br /> T PIPE MATERTA7, (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T z v ip'L r�-w4ezdo a T!6- <br /> A <br /> N <br /> K <br /> S I EXCAVATION SIZE! X " 6 ' X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I /311 <br /> 9� 7i4n r, <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: <br /> LABORATORY: SQA yr�a9L SAMPLERS NAME:IF <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />