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PUBLIC HEA' SERVICES-ENVIRONMENTAL H? TH DIVISION <br /> SITE NAM-W/ / kl�� / ADDRESS�QZ� ���, ,M+ CITY SG6ch lrn <br /> OWNER NAME420w / �� �L OWNER PHONE # &o _ y 66 - X 76 6 <br /> CONTRACTOR,jjrn Q Q CONT. PHONE # zo y_ 6 Z- <br /> FIRE PERMIT # C/ /S <br /> REMOVALS CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR fIF4,4 ,( 4;„ (, DATE L 3 %S TANK # 39 <br /> R RINSED Y N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE Pake"Vkl S �+ Y <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED ff)N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : /0 02 : 40 <br /> 0 <br /> R COMMENTS re <br /> C TANK MATERIAL ( EEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 00 HOLES) <br /> S <br /> T PIPE MATERIAL (LP�EF FIBERGLASS, OTHER) # FEET /Q <br /> PIPE CONDITION (GOOD, P n, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A lAQ 4ico Z - <br /> N - <br /> K <br /> n0 s <br /> S EXCAVATION SIZE /7 X J12— X �_ YDS OF SOIL S �k -t <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P <br /> L v. <br /> I a <br /> N <br /> G <br /> TRENCH DIMENSION /U X X L 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:6w l4ryQ SAMPLERS NAME:r J Sjcua <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />