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PUBLIC HEA-- 3 SERVICES-ENVIRONMENTAL HlTH DIVISION <br /> SITE NAME y✓E f/ <br /> ADDRESS 060 �h�yl v0 CITY, <br /> OWNER NAME (OWNER PHONE <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED (YIN) I METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAS, SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : cG 02: Z j <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIALSTEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) ! p <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) r FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE Ji <br /> T <br /> N <br /> K <br /> rs ' <br /> EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE ( OBSERVATION SAMPLE � <br /> p p <br /> L I T <br /> I P I G <br /> N <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: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />