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PUBLIC HEAltii SERVICES-ENVIRONMENTAL HL,-.,6TH DIVISION <br /> SITE NAME ADDRESS 5(�0�) , F1c e vKrn c� S f. <br /> U C C� Z:Qlz� CITY�7te G/I <br /> OWNER NAME ( OWNER PHONE # <br /> CONTRACTOR Th o O ; I I CONT. PHONE # ao a - <br /> FIRE PERMIT 9g i 3 <br /> REP40VAL_�� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR " e t' DATE p <br /> � '�1�' J TANK # 39 15,5 <br /> R RINSED O/N) I METHOD r RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> LVVAPORS PIIRGED ©/N) METHOD (AMOUNT USED <br /> P READING AT REMOVAL I L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL ( TEL'S, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ( SOIL TYPE ( OBSERVATION SAMPLE <br /> P P <br /> L I � /U <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: S4oL �\/ <br /> LABORATORY: C�zo CSAMPLERS NAME: f <br /> CLOSURE IN PLACE MIXTURE: VOLUME: 71 <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />