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PUBLIC HEAy-, SERVICES-ENVIRONMENTAL Hr,—,TH DIVISION <br /> SITE NAME ADDRESS 5X) E CITY . <br /> OWNER NAME TOWNER PHONE # <br /> CONTRACTOR � � CONT. PHONE # <br /> FIRE PERMIT # TL' 3 <br /> REMOVAL__ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ✓I• 619u DATE, (' , TANK # 39 <br /> R RINSED (5)IN) <br /> I METHOD RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y N) (METHOD _ AMOUNT USED <br /> A <br /> OP <br /> READING AT REMOVAL L.E.L. : , 02 : <br /> R I C0MMENTS <br /> TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> LN <br /> TANK CONDITION (GOOD, -POO HOLES)PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET T <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TY?E OBSERVATION ( SAMPLE � <br /> T <br /> N a j <br /> K �' I I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A _. <br /> M DEPTH ( SOIL TYPE OBSERVATION SAMPLE 4 <br /> P P 11 <br /> L I i I <br /> I P <br /> N E i I <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:THER SAMPLE: <br /> ABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />