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PUBLIC HEALT SERVICES-ENVIRONMENTAL HEP 'H DIVISION <br /> SITE NAMV �� / ADDRESS/o Z_ � 'Frrt„ ,M4- I CITY Sc6u-ham , <br /> OWNER NAME1Zo&_,411;1c31r rj, OWNER PHONE zo 5 - 4�6 - 76 6 <br /> CONTRACTOR;7m 7�'� Q;( CONT. PHONE 6 L- y SVI <br /> FIRE PERMIT 0 95,E /S <br /> REMOVALS CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR rfyk j� DATE L S TANK 0 39 // C S" 03 <br /> R RINSED /N) METHOD RINSE AMOUNT-30 <br /> N RINSATE DISPOSAL SITE VOaWerz0, 1V RM a o 6 1,10-f- (J 0,1, P, I` <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ON) METHOD qr� T, AMOUNT USED 73-A <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS Otx- fir- <br /> C TANK MATERIAL E FIBERGLASS, OTHER) �I�� <br /> 0 <br /> N TANK CONDITIONOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL FIBERGLASS, OTHER) FEET /0 <br /> PIPE CONDITION (GOOD, 00 , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A � - <br /> N u - <br /> K <br /> S EXCAVATION SIZE 'Za! X 4 ' X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATIO SAMPLE { <br /> P P <br /> L <br /> I <br /> N <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 p HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY:�W6.,a 06t SAMPLERS NAME: Lr'( S ti <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />